‘STUDY OF CONCEPT OF ‘PRANA’ IN AYURVED & PHYSIOLOGICAL INTERRELATIONSHIP OF ‘HRUDAYA’, ‘MAHASROTAS’ & ‘PRANA’, WITH RETROSPECTIVE SURVEY STUDY IN CORONARY HEART DISEASE.’

A THESIS SUBMITTED TO BHARATI VIDYAPEETH DEEMED UNIVERSITY, PUNE FOR THE AWARD OF DEGREE OF

DOCTOR OF PHILOSOPHY IN KRIYA SHARIR

UNDER THE FACULTY OF AYURVED

SUBMITTED BY VD. PRASAD DILIP PANDKAR M.D. (KRIYA SHARIR)

UNDER THE GUIDANCE OF PROF. DR. SARITA SUNIL BHUTADA M.D., Ph.D. (KRIYA SHARIR)

RESEARCH CENTRE BHARATI VIDYAPEETH DEEMED UNIVERSITY COLLEGE OF AYURVED, PUNE- 411043.

OCTOBER 2017

PH.D. THESIS

VD.PRASAD DILIP PANDKAR

OCTOBER 2017

‘STUDY OF CONCEPT OF ‘PRANA’ IN AYURVED & PHYSIOLOGICAL INTERRELATIONSHIP OF ‘HRUDAYA’, ‘MAHASROTAS’ & ‘PRANA’, WITH RETROSPECTIVE SURVEY STUDY IN CORONARY HEART DISEASE.’

A THESIS SUBMITTED TO BHARATI VIDYAPEETH DEEMED UNIVERSITY, PUNE FOR THE AWARD OF DEGREE OF

DOCTOR OF PHILOSOPHY IN KRIYA SHARIR

UNDER THE FACULTY OF AYURVED

SUBMITTED BY VD. PRASAD DILIP PANDKAR M.D. (KRIYA SHARIR)

UNDER THE GUIDANCE OF PROF. DR. SARITA SUNIL BHUTADA M.D., Ph.D. (KRIYA SHARIR)

RESEARCH CENTRE BHARATI VIDYAPEETH DEEMED UNIVERSITY COLLEGE OF AYURVED, PUNE- 411043.

OCTOBER 2017

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CERTIFICATE

This is to certify that the work incorporated in the thesis entitled “Study of concept of „Prana‟ in Ayurved & Physiological interrelationship of „Hrudaya‟, „Mahasrotas‟ & „Prana‟, with Retrospective Survey Study in Coronary Heart Disease” for the degree of ‘Doctor of Philosophy’ in the subject of Kriya Sharir under the faculty of Ayurved has been carried out by Vd. Prasad Dilip Pandkar in the Department of Kriya Sharir, Bharati Vidyapeeth Deemed University, College of Ayurved, Pune during the period from September 2012 to October 2017 under the guidance of Prof. Dr. Sarita Sunil Bhutada.

Place: Pune Prof. Dr. Abhijit B. Patil Date: / /2017 B.A.M.S., D.T.F.M., Ph.D Principal & Dean Bharati Vidyapeeth Deemed University College of Ayurved, Pune-43

CERTIFICATION OF GUIDE

This is to certify that the work incorporated in the thesis entitled “Study of concept of „Prana‟ in Ayurved & Physiological interrelationship of „Hrudaya‟, „Mahasrotas‟ & „Prana‟, with Retrospective Survey Study in Coronary Heart Disease” submitted by Vd. Prasad Dilip Pandkar for the degree of „Doctor of Philosophy‟(Ph.D.) in the subject of Kriya Sharir under the faculty of Ayurved has been carried out in the Department of Kriya Sharir, Bharati Vidyapeeth’s College of Ayurved, Pune during the period from September 2012 to October 2017 under my direct supervision/ guidance.

Place: Pune Prof. Dr. Sarita Sunil Bhutada Date: / /2017 Head of Department, Kriya Sharir, GJ Patel Institute of Ayurvedic studies & Research, Anand, Gujrat

DECLARATION BY THE CANDIDATE

I hereby declare that the thesis entitled “Study of concept of „Prana‟ in Ayurved & Physiological interrelationship of „Hrudaya‟, „Mahasrotas‟ & „Prana‟, with Retrospective Survey Study in Coronary Heart Disease” submitted by me to the Bharati Vidyapeeth University, Pune for the degree of Doctor of Philosophy (Ph.D.) in Kriya Sharir under the Faculty of Ayurved is original piece of work carried out by me under the supervision of Prof. Dr. Sarita Sunil Bhutada. I further declare that it has not been submitted to this or any other University or Institution for the award of any degree or Diploma.

I also confirm that all the material which I have borrowed from other sources and incorporated in this thesis is duly acknowledged. If any material is not duly acknowledged and found incorporated in this thesis, it is entirely my responsibility. I am fully aware of the implications of any such act which might have been committed by me advertently or inadvertently.

Place: Pune Vd. Prasad Dilip Pandkar Date: / /2017 M.D. (Kriya Sharir) Research Scholar

ACKNOWLEDGEMENT

I have a great pleasure while keeping this research work in front of reputed personalities in the research. I take this opportunity as a deep sense of gratitude to those people and institution that helped me during this research work.

While going through all those stages of this massive work I had a humble feeling that I am a just a tool at the hands of the almighty Bhagwan, without his mercy nothing was possible for me. I offer my surrender to Bhagvan Dhanvantari, my sadguru Paramapujya Shree Madhavnath Maharaj and Sadguru Shree Rukmangada Swami the great vaishnava & vaidya.

I am very grateful to Hon. Dr. Patangrao Kadam, Founder and Chancellor, Bharati Vidyapeeth Deemed University for giving me a chance to work in this college and for his encouragement and interest in research.

I express deep sense of gratitude and cordial thanks to Hon. Dr. Shivajirao Kadam, Pro Chancellor, Bharati Vidyapeeth Deemed University, for permission for pursuing PhD and motivation.

I express sense of gratitude and offer cordial thanks to Hon. Dr. Manikrao Salunkhe, Vice Chancellor, Bharati Vidyapeeth Deemed University.

I express my sincere thanks and deep sense of gratitude to Hon. Dr. Viswajeet Kadam, Secretary, Bharati Vidyapeeth, Pune.

I have deep sense of gratitude for my guide Dr. Mrs. Sarita Sunil Bhutada, for her incessant encouragement, support and coherent guidance; without which I could not have completed my research. Her valuable direction, precious suggestions, timely discussions, constant

i supervision, continuous support, patience, motivation and immense knowledge helped me a lot throughout the research work. She has been a true friend, philosopher & guide for me. Her advice on both research as well as on my career have been priceless.

I am presenting this dissertation with a deep sincere feeling of gratitude to the respected Principal & Dean Prof. Dr. Abhijit Patil for his encouragement and cooperation in this work.

I am very much thankful to Dr. Asmia Wele, Ex-Dean, Faculty of Ayurved, BVDU, Pune. Her update knowledge in the research methodology gave me great boost during my work.

I am very thankful to Vice - Principals Dr. V. V. Bhalsing and Dr. S. M. Vedpathak for their extended support in this work.

I am very thankful to Dr. Manasi Deshpande, Ex- Dean, Faculty of Ayurved, BVDU, Pune & Academic in-charge, PhD section, BVDU, College of Ayurved, Pune for her unlimited support in this work.

I owed my gratitude to head of department Dr. Mrs. Kavita Indapurkar & my colleagues Dr. Manisha Bhalsing & Dr. Manisha Tate for providing esteem cooperation and constant inspiration and encouragement and also helpful nature during research work.

I offer obligation to Dr. Sachin Kulkarni, Dr. Savita Nilakhe & Dr. Sarita Kapgate for all the help and moral support.

I am also thankful to all faculty & all Staff, department of Cardiology & Cath Lab, Bharati Hospital, Pune, for their kind cooperation in providing patients for interviewing. I am also thankful to all practitioner friends who provided patients.

ii

I am very thankful to my friends Vd. Girish Shirke, Vd. Santosh Deshmukh, Vd. Sai Potdar for all their brilliant remarks and suggestions not only about thesis but on everything during my journey of understanding of ayurveda.

I am very thankful to Prof. Dr. Kalpana Sathe, Dr. Manasi Nimbalkar for their insightful comments and encouragement and for widen my research from various perspectives.

I take this opportunity to express gratefulness to Dr. V. V. Doiphode, Dr. Yashashree Joshi, Dr. Sanjay Pandit, Dr. Madhuri Pawar, Dr. Madhuri Bhide, Vd. Vivek Gokhale, Dr. Supriya Bhalerao, Late Vd. Vilas Nanal Sir for their constant encouragement & guidance.

I also take this opportunity to thank Prof. Dr. Sunil Bhutada for his timely supports & motivations.

I am at fall of words while taking this opportunity to express my gratitude to my Guruji Vd. Samir Jamadagni.

I am very much thankful to all the patients who have participated in this study for sharing their personal information.

I must express my sense of gratitude to all the preceding scholars in the related research area, whose research work helped me as a guideline. I am also thankful to Mr. Salunkhe and all library staff BVDU, COA, Pune for their extended support.

This acknowledgement would be incomplete without expressing profound gratitude which cannot be stated in words towards my father & mother Mr. Dilip Pandkar & Alka Pandkar for the efforts they have taken for my education, for the support, & encouragement. I have no words to express my feelings to my better half Preshita Pandkar. She has taken lots of pain and scarified her priceless time span of long - long six years

iii during my research work. She has constantly encouraged me for the completion of work. Her initiation and support made me complete this work.

Vd. Prasad Dilip Pandkar

iv

KEYS FOR ABBREVIATIONS:

cÉ.xÉÇ. cÉUMü xÉÇÌWûiÉÉ Cha. Charaka Samhita xÉÑ. xÉÇ. xÉÑ´ÉÑiÉ xÉÇÌWûiÉÉ Su. Sushruta Samhita A. xÉÇ. A¹ÉÇaÉ xÉÇaÉëWû Ah. Sa. Ashtanga Sangraha

A. ¾û. A¹ÉÇaÉ=.SrÉ Ah. H. Ashtanga Hrudaya zÉÉ. xÉÇ. zÉÉ…¡ïéûkÉU xÉÇÌWûiÉÉ Sha. Sharangdhar Samhita pÉÉ. mÉë. pÉÉuÉmÉëMüÉzÉ Bha. Bhavaprakasha qÉÉ. ÌlÉ. qÉÉkÉuÉ ÌlÉSÉlÉ Ma. Ni. Madhava Nidana pÉå. xÉÇ. pÉåsÉ xÉÇÌWûiÉÉ Bhe. Bhela Samhita

Ka. Kashyapa Samhita R.V. Ŗgveda A. V. Atharvaveda

xÉÔ. xÉÔ§ÉxjÉÉlÉ Su. Sutrasthana ÌlÉ. ÌlÉSÉlÉxjÉÉlÉ Ni. Nidanasthana ÌuÉ. ÌuÉqÉÉlÉxjÉÉlÉ Vi. Vimanasthana zÉÉ. zÉÉUÏUxjÉÉlÉ Sha. Sharirasthana ÍcÉ. ÍcÉÌMüixÉÉxjÉÉlÉ Chi. Cikitsasthana E. E¨ÉUiÉÇ§É Ut. Uttaratantra mÉÔ. ZÉÇ. mÉÔuÉï ZÉÇQû Pu. Kh. Purva Khanda qÉ. ZÉÇ. qÉkrÉqÉ ZÉÇQû Ma. Kh. Madhyama Khanda

KEYS FOR ABBREVIATIONS:

CHD: Coronary Heart Disease TCM: Traditional Chinese Medicine MI: Mitral Infraction HDL: High Density Lipoproteins LDL: Low Density Lipoproteins NO: Nitric Oxide ROS: Reactive Oxygen Species NIIDM: Non-insulin-dependent diabetes mellitus VEGF: Vascular endothelial growth factor CAD: Coronary Artery Disease HRV: Heart Rate Variability ESR: Electron Spin Resonance PNIE: Psycho Neuro Immuno Endocrinology IGT: Impaired Glucose tolerance ECF: Extra Cellular Fluid INDEX

NO. NAME OF CHAPTER PAGE NO. 1 INTRODUCTION…………………………………….. 1-14

2 AIM AND OBJECTIVES……………………………. 15

3 REVIEW OF LITERATURE………………………… 16-118

3.1 Review of previous work done.

3.2 Review of ‘Prana’.

3.3 Review of Mahasrotas & Hrudaya Sharir.

3.4 Reviews on Ayurvedic Interpretations of CVD. 4 METHODOLOGY…………………………………….. 119-129

5 OBSERVATIONS AND RESULTS………………… 130-186

6 DISCUSSION…………………………………………. 187-264

6.1 Discussion on Conceptual part:

6.2 Discussion on CVD & Observational study:

7 CONCLUSION………………………………………… 265-266

8 SUMMARY……………………………………………... 267-277

9 BIBLIOGRAPHY………………………………………. 278-283

10 ANNEXURE- I: Questionnaire

ANNEXURE- II: Informed Consent Form

ANNEXURE- III: Participant Information Sheet

ANNEXURE IV: Master Data Sheet

ANNEXURE V: Schematic chart for Summary of Prana & some important interrelationships

SUB INDEX (CHAPTER WISE) Chapter No. Title Page No. Chapter: 3.1 1 Review of previous work done 17

Prana in Veda & Upanishad & Yogic 1 20 literature Meaning & significance of prana 2 26

Prana vayu 3 28

Pranavaha srotas 4 32

Prana, Agni & Ahar 5 39

Chapter 3.2 Subtle Prana 6 42

Prana-Mana-Indriya 7 51

Status of prana in diseased condition 8 54

Prana kshaya & vruddhi 9 59

Review of equivalent concepts from 10 other disciplines 62

Mahasrotas sharir 1 66

Importance of mahasrotas 2 68

Gut- Gut microbiota & relations with Chapter 3.3 3 vital organs like brain, heart 69

Hrudaya sharir 4 71

Ayurvedic considerations of Hrudaya 5 & Circulation 73

Review of Modern Aspects of CHD 1 75

Chapter 3.4 Review for Ayurvedic interpretations of

2 CHD 84

Conceptualization of Prana & its Chapter 6.1 Relevance with contemporary health 1 189 sciences

Subtle prana: Guna/Attributes & 2 corollarial functions 198

‘Prana - rakta – agni’: Interrelationship 3 203

Subtle prana & yogik/darshnik 4 concepts & manas 207

Ontological & epistemological appraisal of Prana : Subtle Prana & 5 213 Prana Vayu

Hrudaya- Prana- Mahasrotas 6 220 Interrelationship Chapter 6.2 1 Discussion on CHD & Prana: 226

2 Discussion on observational study 243 ANNEX 3 Schematic chart on ‘prana’ V

Chapter 5: Index for Tables & Graphs

No. Title Page No. for Page No. Table for Graph

1 Distribution According To Hetu: 131 132 Atimatrasya bhojanat 2 Distribution According To Hetu: 132 133 Akale bhojanat 3 Distribution According To Hetu: 133 134 Ahitasya bhojanat 4 Distribution According To Hetu: 134 135 Purisha vega vidharanat 5 Distribution According To Hetu: 135 136 Atyashanat 6 Distribution According To Hetu: 136 137 Ajeernadhyashanat 7 Distribution According To Hetu: 137 138 Doorblagni 8 Distribution According To Hetu: 138 139 Krushatwa 9 Distribution According To Hetu: 139 140 Abhojanat 10 Distribution According To Hetu: 140 141 Vishamashana 11 Distribution According To Hetu: 141 142 Asatmya bhojana 12 Distribution According To Hetu: 142 143 Guru bhojana 13 Distribution According To Hetu: 143 144 Sheet bhojanat 14 Distribution According To Hetu: 144 145 Ati rooksha bhojanat 15 Distribution According To Hetu: 145 146 Sandushta bhojanat 16 Distribution According To Hetu: 146 147 shodhana vibhrama 17 Distribution According To Hetu: 147 148 Vyadhi karshanat 18 Distribution According To Hetu: 148 149 Vega vidharanat 19 Distribution According To Hetu: 149 150 Annanabhilasha 20 Distribution According To 150 151 Lakshana: Aruchi 21 Distribution According To 151 152 Lakshana: Avipaka 22 Distribution According To 152 153

Lakshana: Chhardi 23 Distribution According To 153 154 Lakshana: Krucchra Purisha 24 Distribution According To 154 155 Alpalpa Purisha 25 Distribution According To 155 156 Lakshana: Sashabda Purisha 26 Distribution According To 156 157 Lakshana: Sashoola Purisha 27 Distribution According To 157 158 Lakshana: Atee Drava Purisha 28 Distribution According To 158 159 Lakshana: Atee Grathita Purisha 29 Distribution According Lakshana: 159 160 Atee Bahu Purisha 30 Distribution According To 160 161 Lakshana: Aasyavairasya 31 Distribution According To 161 162 Lakshana: Amlak 32 Distribution According To 162 163 Lakshana: Urodaha 33 Distribution According To 163 164 Lakshana: Udar daha 34 Distribution According To 164 165 Lakshana: aadhman 35 Distribution According To 165 166 Lakshana: aatop 36 Distribution According To 166 167 Lakshana: aanah 37 Distribution According To 167 168 Lakshana: vishtambha 38 Distribution According To 168 169 Lakshana: Gala vidaha 39 Distribution According To Hetu: 169 170 Irshya 40 Distribution According To Hetu: 170 171 Utkantha 41 Distribution According To Hetu: 171 172 Bhaya 42 Distribution According To Hetu: 172 173 shoka 43 Distribution According To Hetu: 173 174 krodha 44 Distribution According To Hetu: 174 175 anashana 45 Distribution According To Hetu: 175 176 Ati maithuna

46 Distribution According To Hetu: 176 177 sandharana 47 Distribution According To Hetu: 177 178 raukshya 48 Distribution According To Hetu: 178 179 Kshudhitasya vyayama 49 Distribution According Hetu: 179 180 Daruna karma 50 Distribution According To Hetu: 180 181 Guru bhojana 51 Distribution According To Hetu: 181 182 Sheeta bhojana 52 Distribution According To Hetu: 182 183 Ati snigdham 53 Distribution According To Hetu: 183 184 Ati matram 54 Distribution According To Hetu: 184 185 Chintyanam Ati chintana

Introduction

Somewhere something incredible is waiting to be known.

(Dr. Carl Sagan) 01 Introduction

Introduction

„To live is to suffer, to survive is to find some meaning in the suffering‟, quotes nineteenth century German philosopher Friedrich Nietzsche. Sufferings & death are integral part of human life. There can be aesthetic viewpoint to explore meaning of life in sufferings, but the life science of ayurveda has methodically criticized this phenomenon of suffering 1 Agnivesha has questioned Atreya, „what are the reasons of vedana i.e. sufferings?‟ Aatreya‟s answer to this question is indeed unique. It‟s at two levels. At philosophical/ metaphysical levels Atreya has answered that upadha (desire in form of wish or envy) is the hetu (cause) of dukha (misery).2 And to reason the sufferings at body & mind level Atreya has enlisted dhee-dhruti-smruti bhramsha, kala & karma & asatmya indriyartha samyog.3 A system of medicine has to be built on some philosophical foundations that can resist change while the external configuration may change by the time. The genius of Indian philosophy which was far ahead then in drawing conclusions for the problems related with the existence of universe and human, served as the backbone of the development of medical science in India. Ayurveda, in its literal sense, is the knowledge or science of life. P. C. Ray has mentioned the long phase of India‟s cultural history from 600 BC to AD 800 as the „Ayurvedic period‟ because he credited Ayurveda with the origins of not only medical sciences but also chemistry and, if one may add, plant and animal sciences as observed by Dr. Valiathan.4 That is why Ayurveda is perhaps the only science in the world wherein are mingled together a health science, philosophy (darshana), psychology and even anthropology.

It is carrying a legacy of 5000 years of oriental scientific theories, over 7000 formulations, symptomatology & disease diagnostics.

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01 Introduction

Conventionally Ayurveda is believed to be upaveda of atharva veda. According to belief it is apauresheya i.e. not created by humans. Some mentions like „Seers saw the shad padartha…‟ as in Charaka Samhita validate the same. This legacy of original oriental knowledge was later blended with contributions at principle & practical level experiences of the medieval & modern scholars. „Ayurveda the Indian heritage and is a continuously evolving health tradition. Ayurveda reveals an interesting journey from mythology to logical, rational and evidence‑based practices,‟ observes Dr. Patwardhan Bhushan.5 Laghu trayee comprising bhavaprakasha, madhava nidana & Sharangadhara show many unique features like extensive usage of guggulu kalpana, nomenclature of newer symptoms & diseases & incorporation of many newer herbs which cannot be traced back in bruhattrayee literature are to name a few. This progression and expansion ayurveda could be endorsed to the requisites of the particular times.

Ayurveda stands as an important non conventional medicine of today‟s world. Today‟s plural medical world is optimistic about Ayurveda. As quoted in annual report of department of AYUSH, „The demand for pluralism in healthcare appears to be based on a realistic assessment of the inadequacy of any single system of healthcare to solve all contemporary health needs.‟6 In same regards today‟s world is trying to explore solutions for its modern day health issues from Ayurveda.

The moment one starts to explore Ayurvedic viewpoint of some so called „modern day disease‟, begins the real question. Ayurveda is not based on same basic sciences or sister concerns on which today‟s western biochemical science is based upon. Where western health sciences are based on biophysics & bio chemistry, Ayurvedic sister concerns are samkhya, nyaya, vaisheshika, Mimamsa, Vedanta & more darshan

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01 Introduction

shastra. Western health science is an evidence based science whereas Ayurveda is an experience based science as said popularly.

Ayurvedic viewpoint is holistic & systemic unlike western world‟s structural & reductionist one. The methods of acknowledging ecosystem & human systems in ayurveda and western sciences are primarily different. Western biomedical sciences opted to go for detailed knowledge about parts of physical and biological nature, whereas oriental systems have a holistic knowledge of the physical, biological, and spiritual fields of same.

Hence it must be very clear at beginning itself that, Ayurveda is not only some traditional formulary, but it is a science enriched with its own concepts of physiology, pathology & medicine. As observed by today‟s eminent health science scientist, „Ayurvedic fundamental concepts like Dosha, Dhatu, Rasa, Guna, Agni, Srotas, Ojas, Ama, Prana, Kosha, Nadi etc., have the “potential” to offer ground-breaking leads to the future of medicine, health and wellness. The real question is how to “translate” this potential in actual benefits to science and people. We must revitalize the legacy of Charaka, Sushruta, Vagbhata and many others to liberate Ayurveda from being a frozen ritualistic tradition into a living tradition.‟7

There is a need to not only translate but to illuminate & to paraphrase such Ayurvedic terms/concepts. Again this paraphrasing is indeed a cautious job as there is a substantial epistemological difference between ayurveda & western health sciences. As pointed out by Prof. Singh RH, „Conventional biology works largely in a structure dominated approach with emphasis on narrow structure-function relationship and cause- effect duality. In contrast Ayurvedic biology prefers to adopt a broad holistic approach irrespective of narrow cause-effect relationship.‟8

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01 Introduction

That is why the job of illumination of Ayurvedic terms must not be done using „one as to one‟ prototype. Concept of ayurvedic physiological elements is far inclusive. Instead of „one as to one‟ there is a relation of „part & whole.‟ As reported by Darshan Shankar, „ It is obvious that the whole and part are related, but the key point to be understood is that the relationship is not one to one because the whole is not equal to the part, nor does the sum of parts add up to remake the whole. One should therefore not be seeking equivalence in developing the relationship between Ayurveda and Western sciences, otherwise one will either reduce the whole to a part, or assume that the part represents the whole, and thus develop a distorted understanding.9 Thus there is a need to explore Ayurvedic terminology in its own epistemological viewpoint.

„Prana’ is an important & pivotal term as well a concept not only in Ayurvedic literature but also vedic & allied literature. As Charaka rightly points out Ayurveda seeks to quench / satisfy three basic needs of human beings: Pranaishana (Desire to live) Dhanaishana (Desire to earn) and Paralokaishana (Desire to perform virtuous acts to achieve emancipation). Thus prana is a term synonymous to life. Prana is a term that is used for „vitality element‟ as well as for „vata dosha’. Mark Micozi has observed that, „Asian medicines share few things in common particularly emphasis on vitality elements. Although western sciences & medicine given it up concept of vital energy was central amongst Asian medical practices.‟10 „Prana’ is the relevant ayurvedic term.

Alike modern sciences, Ayurvedic discipline has used many synonyms for a single element ex. some sharir bhava or herbs and a single term is again used for variety of meanings. Each synonym reflects its unique shade of meaning & has got its own practical application too. In classics term „Prana’ is used in variety of sense / meanings.

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01 Introduction

Ayurvedic sharir concepts are unique. Dosha, dhatu & mala are considered as basic elements of body physiology. Dosha are bioenergetic entities of body whereas dhatu are structural units. Purusha is said to be made up of different Srotasa. Sharir elements of purusha are nurtured by elements from loka as both of them are panchabhautika. This process of conversion to sharir elements takes place in different „srotas’. This process of conversion i.e. „sthoola’ and „sookshma’ pachana is done by „jatharagni’ and „dhatwagnis & bhootagnis’ respectively.

Dosha is a central concept of Ayurvedic physiology, pathology & medicine. „vayu’ is considered as controller of body in structural & functional sense.11 Vayu is equivalent with aayu & bala. Vayu is considered to be controller of body activities & hence is equated with universe as well as lord.12

Most often prana is considered as 1st swaroopa of vata dosha amongst five of them where rest of four are udana, vyana, samana, apana. It is said to be located in moordha, ura, kantha, jivha, aasya & nasika. Prana vayu is responsible for shtheevana, kshavathoo, udgar, shwasa & ingress of aahar.13 Sushrutacharya refers nabhi as place of prana.14 In same place sharira sthana, Sushrutacharya has enlisted agni, soma, vayu, satwa, raja, tama five indriya & bhootatma as equated with prana.15 Pranayatana is a unique concept in Ayurveda. Charakacharya has mentioned some sites in body as seat of prana. Shankha, three marma (hrudaya, basti, shira) , kantha, rakta, shukra & oja.16 There is also mention of special interrelationship of prana & rakta. Charakacharya also mentions particular mutual relationship of prana & prakruta rakta on whch depends bala, varna, sukha & aayu.17 In Sharangadhara Prana is quoted to be located at nabhi.18 This vitality element of prana & prana vayu ultimately dependent on agni, according to Charakacharya.19

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01 Introduction

Many more such references of „prana’ are seen in classics. Hence there is a need to compile, understand and criticize all such references of prana & to put forth a comprehensive understanding of „prana’. This complexity of prana is indeed needed to be addressed. Dr Singh R H has observed that, „If each one of the seven Dhatus are separated from the body what remains behind is the energetic life process i.e. the Prana which is the coordinating force for all structural and functional attributes in a quantum manner. Everything is the integral part of the organism. This is the quantum basis of the understanding of Ayurvediya Kriya Sharira.‟20

Relevance of prana/prana vaha srotas in diseased status:

Concept of prana is pivotal in core theories of ayurveda as well as in clinical applications of ayurved. Charaka quotes that the phenomenon of „life‟ depends on „prana’ itself.21 Ayurvedic sharir concepts are unique & are observed in chikitsadhishthita purusha & not dead bodies. Srotas is that kind of concept of which there are more of physiological deliberation than anatomical one. According to Charakacharya „hrudaya’ & „mahasrotas’ are moolasthana of pranavaha srotas.22 Chakrapani quotes it as srotas of prana vayu only and further clarifies this is not contradictory with the fact that vayu is carried by dhamani.23 According to commentator Gangadhara, „vaksha’ is the expected meaning of „hrudaya’ in this case. The whole cardiopulmonary apparatus is meant by this term. Gangadhara explains Mahasrotas as „mahachhidram mahasaranam’. This clearly means the whole alimentary canal starting from mouth up to anus.24 According to Sushrutacharya „hrudaya’ & „rasavahi dhamani’ are moolasthana of pranavaha srotas. Dhamani are channels meant for carrying body elements.25 Consideration of „mahasrotas’ as a „moolasthana of pranavaha srotas’ as in Charak

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01 Introduction

samhita is praiseworthy consideration, as this classic belongs to school of physicians. „Mahasrotas’ is place of jatharagni, process of awasthapaka (& hence place for udirana of dosha) & pachana. Mahasrotas is also considered as „abhyantar roga marga’ among three of roga marga. Unique shodhana treatments of vamana, virechana & basti are done via mahasrotas only. Hence role of Mahasrotas in physiology of pranavaha srotas is needed to be explored.

According to ayurvedic discipline Pranavaha srotodushti lakshana include atisrushta (fast/speedy) , atibaddha (obstructed), kupita (vitiated) , alpalpa (undersized/ shallow) , abheekshana (with increased frequency) , sashabda (with sound), sashoola (painful) ucchawas i.e. expiration26 Shwas kruchhrata/ shwas is lakshana in many vyadhi as well as in swatantra „shwas vyadhi’. „Dyspnea‟ is a relevant modern term.

CHD (coronary heart disease) is an important disease of heart in today‟s era essentially showing dyspnea as its cardinal symptom & pranavaha srotodushti.

Coronary heart disease:

Historians studying the shift in epidemiology from infectious to chronic disease in the decades following the Second World War have stressed the forceful role of two major research programmes, one focusing on the aetiology of lung cancer the other coronary heart disease (CHD).27 & 28 First Known Use of the term „Coronary heart disease‟ was in 1949.29 „Coronary heart disease‟ is defined as progressive reduction of blood supply to the heart muscle due to narrowing or blocking of a coronary artery (atherosclerosis). Short-term oxygen deprivation can cause angina pectoris. Long-term, severe oxygen depletion causes a heart attack, bypass or angioplasty is needed if medication and diet do not control the disease.30 Coronary heart diseases (CHD) have reached epidemic

7

01 Introduction

proportions among Indians. India is undergoing a rapid health transition with rising burden of CHD with a two-fold rise in rural areas and a six- fold rise in urban areas between the years 1960 and 2000 particularly in last two decades. Studies among Indian migrants in various parts of the world have documented an increased susceptibility to CHD in comparison to the native population studied. Prevention is based on causative factors.31

Conventionally risk factors for coronary artery disease are listed as high LDL cholesterol, low HDL cholesterol, high blood pressure, family history, diabetes, smoking, being post-menopausal for women and being older than 45 for men & Obesity. Scientific world has already chalked out the programs for prevention of CHD as heart healthy eating, maintaining healthy weight, managing stress, quitting smoking & physical activity.32 World Health Organization (WHO) has proclaimed that the major causes of chronic diseases are known, and if these risk factors were eliminated, at least 80% of all heart disease, stroke and type 2 diabetes would be prevented; over 40% of cancer would be prevented.33 In spite of plenty of researches & publications on preventive cardiology, CHD still continues to be a mega threat for human health & life. This is simply because of complexity of aetiopathology of CHD. Gerald M concludes that, „Cohort study design, almost universally applied in major CHD investigations in the United States, allowed epidemiologists to manage multiple aetiological hypotheses, calculate morbidity incidence, and define the natural history of the disease. Unlike lung cancer, where one powerful determinant dominated, CHD epidemiology reported multiple „risk factors‟ producing small effects. Causal relations, especially in the absence of clinical trials, proved difficult to establish. Despite this difficulty, CHD epidemiologists pressed physicians to begin modifying risk factors in „susceptible‟ patients. That clinical rather than

8

01 Introduction

environmental risk facts predominated may have made medical suasion easier.‟34

Here an Ayurvedic viewpoint can indeed add a value in not only preventive cardiology as well as in management of it. Ayurveda is a system of medicine with its own ideology of sharir (anatomy & physiology), hetu & samprapti (aetio-pathology) & medicine. Many scholars have proved efficacy of Ayurvedic herbs/herbomineral preparations on different cardiac ailments diagnosed according to conventional biochemical medicine. Alcoholic extract of the bulb of Allium ascalonicum (single clove garlic) showed prominent anticoagulant, fibronoloytic and hypocholesterolaemic activity in rabbits.35 Some studies reveal that garlic inhibits human platelet aggregation and hence could be useful in the avoidance of myocardial ischemia.36 The plant is also said to be helpful in preventing restenosis of artery after coronary angioplasty. Rhizome of Curcuma longa Linn. (turmeric) and active principle curcumin possess hypolipidemic effect, also anti atherosclerotic action.37 Oral administration of a turmeric extract inhibits LDL oxidation and has hypocholesterolemic effects in rabbits with experimental atherosclerosis and antithrombotic effects.38

Thus many research works are seen focused on conventionally proven risk factors. And efficacy of Ayurvedic medicines on same risk factors like Hypercholesteromia & allied CHD in above case. But ayurveda is not drug oriented but a rogee (patient) oriented system of medicine. There is need to understand that apart from works on validation of cardiotonic herbs & formulations, we need to revisit pathohysiology of CHD in Ayurvedic epistemological point of view. Hrudaya as a site of prana & moolasthana of pranavaha srotas is needed to be explored in same context. Role of rasavaha & pranavaha srotas & vitiation of sira in CHD

9

01 Introduction

is too explained by some scholars.‟39 However role of „prana’ in CHD is needed to be explored. It will be more appropriate to study mahasrotas in same context as same is moolasthana of pranavaha srotas along with hrudaya. And thus physiological interrelationship of hrudaya, mahasrotas & prana will be explored.

Hypothesis:

Hrudaya & mahasrotas are moolasthana of one & same srotas i.e. pranavaha srotas. Asssociation of these two might be seen reflected in pranavahasroto dushti ex. CHD. Retrospective observational study of CHD subjects may be fruitful in same regards. And thus physiological interrelationship of hrudaya, mahasrotas & prana can be explored.

Study design:

Scheme of chapters: In this thesis; the subject has been elaborated as follows:-

Introduction: Significance and scope of present study, hypothesis, are discussed in brief. Overall concept of the study is put forth.

Review of literature: Extensive literary review was carried out for „concept of Prana’, Mahasrotas, Hrudaya Sharir, modern Aspects of CHD & Ayurvedic Interpretations on CHD.

Aim & Objectives: The study was aimed to make a fundamental understanding of term „prana’ in Ayurveda with literary study & to explore the physiological

10

01 Introduction

interrelationship of ‘hrudaya’, ‘mahasrotas’ & ‘prana’, with observational study in coronary heart disease. Relevant objectives related to same are written in this topic.

Methodology: It was a two phase work. Study of concept of prana in ayurveda was a fundamental kind of study done with literary method. To verify the perception of principles that was made in literary study, an observational study (with survey as a tool) was planned. All sub tasks in designing of Questionnaire for assessment of functional status of Mahasrotas and pranavaha & rasavaha srotas are elaborated.

Observations: All observations for all questions of questionnaire assessing lakshana & hetu of annavaha, purishavaha, pranavaha & rasavaha srotas are put in chart as well in bar diagrams.

Discussion & Conclusion: Outcomes of conceptual study are discussed in seven subchapters. Observations of observational study are discussed elaborately. Schematic chart for understanding of prana & its relationships is prepared.

Summary: The whole study has been summarized.

11

01 Introduction

REFERENCES:

1 Ch. Sha. 1/13

2 Ch. Sha. 1/95

3 Ch. Sha. 1/98

4 Valiathan MS., An Ayurvedic view of life, Current Science, May 2009; VOL. 96: 9- 10

5 Patwardhan B., Traditions, rituals and science of Ayurveda, J Ayurveda Integr Med 2014;5:131-3.

6 Annual Report of Dept of AYUSH, Planning Commission, Govt. of India. 2008

7 Patwardhan B. Traditions, ri18tuals and science of Ayurveda. J Ayurveda Integr Med 2014;5:131-3.

8 Prof. R.H. Singh Towards Quantum Biology : The Ayurvedic Perspective Annals of Ayurvedic Medicine Vol-3 Issue-1-2 Jan.-June, 2014

9 Darshan shankar J Ayurveda Integr Med. 2010 Jan-Mar; 1(1): 3–5. doi: 10.4103/0975-9476.59817

10 Mark S. Micozzi, Vital healing, Jessica kingslay publishers, Google books.

11 Ch. Su.12/8

12 Ch. Chi. 28/3

13 Ch. Chi.28/5-6.

14 Su.Sha.7/5

15 Su. Sha. 4/3

16 Ch. Su. 29/3-4

17 Ch. Su.24/4

18 lÉÉÍpÉxjÉÈ mÉëÉhÉmÉuÉlÉÈ xmÉ×wOèuÉÉ ™iÉMüqÉsÉÉliÉUqÉçI MühPûɯÌWûÌuÉïÌlÉrÉÉïÌiÉ mÉÉiÉÑÇ ÌuÉwhÉÑmÉÉSÉqÉ×iÉqÉçII mÉÏiuÉÉ cÉÉqoÉUmÉÏrÉÔwÉÇ mÉÑlÉUÉrÉÉÌiÉ uÉåaÉiÉÈI mÉëÏhÉrÉlSåWûqÉÎZÉsÉÇ eÉÏuÉrÉgeÉPûUÉlÉsÉqÉç II Sh. Pu. 5/47

12

01 Introduction

19 Ch. Chi.15/4 mÉëÉhÉÉ CÌiÉ mÉëÉhÉÉmÉÉlÉÉåmÉsÉͤÉiÉÉÈ mÉgcÉÉÌmÉ uÉÉrÉuÉÈ I ÌMÇüuÉÉ mÉëÉhÉ CÌiÉ zÉoSålÉ ÌlÉirÉÇ oÉWÒûuÉcÉlÉÉliÉålÉÉåcrÉiÉå rÉjÉÉmxÉUÈzÉoSålÉ LMüÉÌmÉ ÌuɱÉkÉUÏ MüШÉïrɨÉåI (Chakrapani)

20 Singh R H, editorial, Annals of Ayurvedic Medicine Vol-3 –Jan 2014

21 Ch. Chi. 28/234

22 Ch. Vi. 5/8

23 cÉ¢ümÉÉÍhÉÈ mÉëÉhÉuÉWûÉlÉÉÍqÉÌiÉ uÉÉiÉxÉÇ¥ÉmüuÉÉiÉuÉWûÉlÉÉqÉçI LiÉŠ mÉëÉhÉÉZrÉÌuÉÍzɹxrÉ uÉÉrÉÉå ÌuÉÍzɹx§ÉÉåiÉ: I xÉÉqÉÉlrÉålÉ iÉÑ uÉÉrÉÉåÈ LuÉ kÉqÉlrÉ CÌiÉ lÉ ÌuÉUÉåkÉÈ qÉÔsÉÍqÉÌiÉmÉëpÉÉuÉxjÉÉlÉqÉç

24 aÉÇaÉÉkÉU: qÉÔsÉiÉÉå urÉÉZrÉÉrÉiÉå IiɧÉåirÉÉÌS iÉ§É mÉëÉhÉÉÌSuÉWåûwÉÑ x§ÉÉåiÉÈxÉÑ qÉkrÉå ™SrÉÇ uɤÉÈ, qÉWûÉx§ÉÉåiÉxÉ¶É qÉWûÉxÉUhÉçÇ qÉWûÉÎcNûÌSìèqÉirÉjÉïÈ I

25 Su. Sha. 9/12

26 Ch. Vi.5/8

27 Susser M. Epidemiology in the United States after World War II: The evolution of a technique. Epi Rev 1985;7: 147–77.

28 White C. Research on smoking and lung cancer: a landmark in the history of chronic disease epidemiology. Yale J Biol Med 1990;63:29–46.

29 Edward Lew Some implications of mortality statistics relating to coronary artery disease Journal of Chronic Diseases Volume 6, Issue 3, September 1957, Pages 192-209

30 Medical Dictionary Merriam Webster http://www.merriamwebster.com/dictionary/coronary%20heart%20disease

31 Vamadevan S. Ajay & Dorairaj Prabhakaran Coronary heart disease in Indians: Implications of the Interheart study Indian J Med Res 132, November 2010, pp 561-566

32 http://www.nhlbi.nih.gov/health/health-topics/topics/hd/prevent

33 http://www.who.int/chp/chronic_disease_report/part1/en/index11.html

34 Gerald M Profiling risk: the emergence of coronary heart disease epidemiology in the United States (1947–70) Int. J. Epidemiol. (June 2006)35 (3): 720-730. doi:10.1093/ije/dyl014

13

01 Introduction

35 Khare CP. Indian Medicinal Plants – An Illustrated Dictionary. 2nd Indian Reprint. New Delhi: Springer (India) Pvt. Ltd.; 2007. p. 33.

36 Amroyan E, Gabrielian E, Panossian A, Wikman G, Wagner H. Inhibitory effect of andrographolide from Andrographis paniculata on PAF induced platelet aggregation. Phytomedicine 1999;6:27:31.

37 Ramírez Tortosa MC, Mesa MD, Aguilera MC, Quiles JL, Baró L, Ramirez Tortosa CL, et al. Oral administration of a turmeric extract inhibits LDL oxidation and has hypocholesterolemic effects in rabbits with experimental atherosclerosis. Atherosclerosis 1999;147:371:8.

38 Olajide OA. Investigation of the effects of selected medicinal plants on experimental thrombosis. Phytother Res 1999;13:2312.

39 Rapolu Sunil Buchiramulu, A Valuable Explanation of The Cardiovascular System By Ancient Ayurvedic Science Pioneers, Int. J. Res. Ayurveda Pharm. 5(3), May - Jun 2014

14

Aim

Basic scientific research is scientific capital.

(Vannevar Bush) 02 Aim & Objectives

Aims & Objectives

Study of concept of prana in ayurvedic epistemological viewpoint was planned. It was a conceptual & literary study. To verify the perception of principles those was made in literary study, an observational study (with survey as a tool) was planned. Functional status of Mahasrotas and pranavaha & rasavaha srotas was evaluated, with a specially designed questionnaire.

Aim:

i. To make a fundamental understanding of term ‘prana’ in Ayurveda with literary study. ii. To explore the physiological interrelationship of ‘hrudaya’, ‘mahasrotas’ & ‘prana’, with observational /survey study in coronary heart disease.

Objectives:

i. To compile references of term ‘prana’ from ayurvedic literature & study them in sharir kriyatmak perspective. ii. Fundamental assessment of concept of prana & ayurvedic physiological relation of prana- hrudaya- mahasrotas, and also with rasavaha & pranavaha srotas. iii. To study CHD subjects with a specially designed questionnaire for the detailed status of mahasrotas in them. iv. To explore the physiological interrelationship of hrudaya, mahasrotas & prana with help of retrospective observational study.

15

Review of Literature

Epistemology without contact with science becomes an empty scheme. Science without epistemology is insofar as it is thinkable at all primitive & muddled.

(Albert Einstein)

03 Review of literature

Review of literature

It is subdivided under following headings.

A) Review of previous work done. B) Review of ‘Prana’. C) Review of Mahasrotas & Hrudaya Sharir. D) Review for Ayurvedic Interpretations on CHD.

16

03 Review of literature

A) Review of previous works done: 1) Prana evam Pranayatanon ka vivechnaymak adhyayan. (1985) National Institute Of Ayurveda, Jaipur- Rajasthan. 2) Pranavaha srotas vivechan(1988) National Institute Of Ayurveda, Jaipur- Rajasthan. 3) Pranavaha sroto dushti janya rog Rajyaksma, Shwasa, Kasa mein kapha ka pareekshanatmak adhyayan. (1990) National Institute Of Ayurveda, Jaipur- Rajasthan. 4) Pranavaha srotas ka shareer kriyatmak adhayayn.(1992) National Institute Of Ayurved, Jaipur- Rajasthan. 5) Pranavaha Srotas kriya-vikritijanya shvasa roga mein shvasahara Mahakashay ka prabhavatmak adhyayan. (2001) National Institute Of Ayurveda, Jaipur- Rajasthan. 6) Ayurvedeeya chikitsa vangamay mein varnit Prana evam pranayatana ka vaigyanika vivechanatmak adhyayan. (2002) Govt. Ayurved College Raipur- Chattisagrah. 7) Pranavaha srotas avayava nishchitikaran. (2001) SRK Toshniwal Ayurved Mahavidyalaya, Akola- Maharashtra. 8) A study of pranavaha srotas with special emphasis on management of Tamak Shvasa with virechana & Haridra Choorna. (2004) Dr. BNM Rural Ayurvedic Medical College, Bijapur- Karnataka. 9) A critical & co-relative study of Pranavaha Srotas. (2006) NK Jabashetti Ayurved Medical College, Bidar- Karnataka. 10) A conceptual study of pranavaha srotas in Ayurved in relation to its anatomical and physiological implications. (2004) IMS faculty Of Ayurveda BHU, Varanasi- UP 11) Sroto-vivechan, visheshatah Pranavaha ka srotas ke sandarbha mein.(1990) Govt. Ayurved College & Hospital, Gwalior- MP.

17

03 Review of literature

12) Vata-dosha vivechana, visheshatah Prana-vayu ka sameekshanatmak adhyayan. (1990) Govt. Ayurved College & Hospital, Gwalior-MP. 13) Pranayam ka Pranavaha srotas par prabhav agni ke vishesh sambandha mein. (1998) Govt. Ayurved College & Hospital, Gwalior-MP. 14) Pranavaha srotas par pranayam ka prabhav.(1997) Govt. Ayurved College & Hospital, Gwalior-MP. 15) Vriddhawastha evam pranavaha sroto-vikruti.(1968) IPGT & RA Gujrat Ayurved University, Jamnagar- Gujrat. 16) Study of pranavaha srotas. (1970) IPGT & RA Gujrat Ayurved University, Jamnagar- Gujrat. 17) Study of pranavaha srotas w.s.r. to its aetio-physiological approach. (1993) IPGT & RA Gujrat Ayurved University, Jamnagar- Gujrat. 18) Pranavaha sroto-vigyan. (1963) IPGT & RA Gujrat Ayurved University, Jamnagar- Gujrat. 19) Srotonusar nidan chikitsa (Pranavaha srotas par naidanika, shodhana-shamana chikitsatmak andhyayan) (1967) IPGT & RA Gujrat Ayurved University, Jamnagar- Gujrat. 20) Charak Samhitecha chikitsa sthanateel Pranavaha, annavahava udakvaha srotasachya vyadhi chikitsa ahara kalpanecha vaprache mahatwa- Tulnatmak adhyayan. Ashtang Ayurved Mahavidyala, Pune- Maharashtra. 21) Prana shakti ka moola-srotas: Ek Shastreeya evam prayogika adhyayan.(2006) Govt. Ayurvedic College & Hospital, Lucknow- UP. 22) Rakta- Raktagni evam Prana-vayu ka parisparik sambandha ka tulnatmak adhyayan. (1991) Shri Ayurved Mahavidyalaya, Nagpur- Maharashtra.

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03 Review of literature

B) Literary Review of prana:

Reviewing references of prana is a huge task. Hence it is divided under following subtitles.

1) Prana in Veda & Upanishad & Yoga literature 2) Importance of prana 3) Prana vayu 4) Pranavaha srotas 5) Prana, Agni & Ahar 6) Subtle Prana 7) Prana-Mana-Indriya 8) Status of prana in diseased condition 9) Prana kshaya & vruddhi 10) Review of equivalent concepts from other disciplines

19

03 Review of literature

1) Prana in Veda & Upanishad & Yoga literature

Prana the vital element, the vayu & phenomenon of respiration was pivotal amongst oriental sciences & religious practices of ancient India. There are plenty of references of prana in vedic, upanishadik & yogic literature.

Sr.No. Grantha No. of references 1 Bhawadgeeta 13

Darshan shastra

2 Karma Mimamsa 04

3 Nyaya Darshana 00

4 Samkhya Darshana 02

5 Vaisheshika Darshana 00

6 Vedanta Darshana 12

7 Yoga Darshana 02

Purana No. of references 8 Agni Purana 116

9 Bhagwat Purana 190

10 Brahma Purana 101

11 Vishnu Purana 41

Upanishada No. of references

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03 Review of literature

12 Isha 00

13 Kena 07

14 Katha 04

15 Prashna 36

16 Manduk 14

17 Mandukya 00

18 Aitariya 07

19 Taitariya 23

20 Shwetashwetar 04

21 Chhandogya 114

22 Brihataaranyak 130

23 Kaushitaki 54

24 Jabal 03

25 Mahnarayan 21

26 Paingal 07

In these references term prana is used in different contexts. They can be reviewed & summarized under following subheadings.

a) Importance of Prana b) Prana in context with yoga c) Prana as Soma d) Prana – Agni Interrelationship e) Concept of Pranamaya kosha f) Remarks

21

03 Review of literature

a) Importance of Prana:

The science of prana i.e. ‗prana-vidya’ is given as much importance that it is said equivalent with atharva vidya.1 Vedas believe Surya (sun) is responsible to empower prana i.e. life force.2 All of living & nonliving creatures (chara & achara) are depending on principle prana.3 Prana is responsible for life, death & illnesses. & hence one shall do upasana of prana principle.4 Present, past & future all of three phases depend on prana principle.5 Prashnopanishada traces utpatti of prana right back to aatma. It also mentions that prana assigned different indriyas & its subtypes (prana, vyana,udana, apana, samana) their function & locations.6 Upanishadic literature quotes prana as a precursor of all. Prashnopanishada quotes that, ‗Once prana said to bhoota & antakarana chatushtaya that now it will devide itself into 5 types for dharana of sharir. Kindly do not get confused (moha grasta) with this differentation. But they (bhoota & antakarana chatushtaya) did not believe him i.e. prana.7 Thus prana is considered as precursor. Kathopanishada refers that the one devtaswaroop aaditi which appears in form of prana, resides in buddhiroopi guha & is generated with bhootas is the same principle (brahma) asked by you (Nichiketa).8 Kathopanishada even quotes that the one who propels Prana in upward direction, apana in downward direction is residing in madhya (hrudaya) & is worshipped by all.9 Mundakopanishada mentions genesis of akshara brahma followed by genesis of prana & later mana, indriya & panchamahabhoota are said to be originated from prana.10 One may find prana been praised in many references in prashnopanishada.

b) Prana in context with yoga:

Science of yoga is the oriental heritage again based on basic concept of prana. ‘Prana’ & ‘apana’ are considered to be shakti. One shall control his Prana & Apana are responsible for life, death, long life & medha.11

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03 Review of literature

Samaveda too mentions that bala is derived from prana & Apana shakti.12 Bhagvadgeeta has refered to different modes of sacrifices in fourth chapter, Some yogis scarify all functions of their sense organs & those of prana in the fire of yoga which is nothing but a form of self- control.13 Whereas some other yogis amalgam their prana into apana or vice versa. Some others regulate their diet & practice pranayama & thus are able to pour prana (vitality) in prana (pranamaya kosha).14 In Bhagvadgeeta there is also mention of a practise of equalization of prana & apana by which a contemplative soul intent on liberation & becomes free from desire, fear & anger.15Prashnopanishad mentions that Ucchwas & Nishwas are like aahuti & sama i.e. equal distribution of it is done by samana vayu.

Aptly used techniques based on yoga, pranayama & asana a kundalini gets awakened & prana gest dispersed in shoonya. It is known as laya of prana.16 Union of apana & prana & kshaya of mala & mootra can transform old person in younger one.17 c) Prana as soma:

‘Prana’ shakti is nurtured by aagneya as well soma shaktis. It‘s not only surya but also Chandra, quotes atharvaveda.15 Varchas/tejas are synonymous with ojus in vedic literature. Varchas empowers prana shakti refers yajurveda 7/26.16 According to prashnopanishad, Aaditya is prana & rayi is chandrama. All moorta & amoorta are forms of rayi, where Prajapati united rayi & prana for srushti utpatti is the basic concept in Upanishad.17 d) Prana-Agni Relationship:

Prana is said to be dependent on agni at many places. This is important as in ayurveda prana vayu & subtle prana are said to be dependent on agni only. Agni gives bala to ‗prana principle’ & thus to life. As in Atharva

23

03 Review of literature veda 8-2-13.18 At another place chandrama is equally believed to nurture prana along with agni.19 It is said that Yagna improves one‘s Prana & apana shaktis. & he do not have bhaya I.e. fear for mrutyu i.e. death Atharvaveda 8/1/5.20

Atharvaveda quotes that for longevity of life one shall achieve darshana shakti from surya i.e. sun & pranashakti from vayu.21 Prashnopanshada quotes that vishwaroopa prana is vaishwanar i.e. agni, as said by Ruk (rishi). Thus prana is equated with vaishwanar.22 prashnopanishada 1-1- 7 Apana & prana get merged with agni. Blended with prana agni becomes empowered.23

The interrelationship of prana with agni is very clearly stated by Bhagvadgeeta. Chapter fifteen mentions thet bhagvan himself takes form of agni in all body creatures & unites with prana & apana so as to digest four kind of ingested foods.24

e) Concept of Pranamaya Kosha:

The concept of pancha-kosha includes five sheaths. From external to internal levels they are, gross organic level of existence (Annamaya kosha), Bio-energy level of existence (Pranamaya kosha), Psychoenergy level of existence (Manomaya kosha), Level of insightful existence (Vijnanmaya kosha) and Level of Delightful existence (Anandamaya kosha). Aatma resides in hrudayakasha. Manomay & pranaswaroop aatma resides in hrudaya in annamaya purusha Panchakosha.25 Pranamaya kosha is the kosha of vital energy.

Annamaya (physical, matter) kosha is the layer where our physical sensations are felt and all our elements and minerals come together as the material body. Yoga postures (Yogasanas) operate at this level of

24

03 Review of literature organization. Pranamaya (physiological, vital energy or air) kosha represents our vital energy body. This physiological sheath is where we breathe and observe our heart beating for example. Through the practice of appropriate breathing and breath control exercises (pranayama) ―we remove the random agitations in pranic flows and ailments are handled at this kosha level.‖26

Manomaya (mental, or mind) kosha is the sheath where our emotions, thinking, feelings and desires are grouped together. During the dream- state this kosha brings together many aspects of the mind. It is also where the ego can create obstacles, and ―psychosomatic factors causing physical illness begin their journey into the body‘s cell structure resulting in a breakdown of tissue‖.27 Optimal functioning at this level, according to Patanjali‘s Yoga Sutras, is facilitated through dharana (concentration exercises) and dhyana (meditation, or spiritual contemplation). These practices may ultimately lead to Samadhi (or super-consciousness).

It is interesting to note that pranamaya kosha serves as mediator between annamaya kosha & manomaya kosha.

f) Remarks:

Both of ayurveda & yoga have adopted theory of five types of vata & importance of prana & its location as hrudaya & its transport in body through different vessels. Yogic idea of prana is more related with mind & its movement through ida, pingla & sushumna nadi. Yoga adds five subtypes of vata (naga vayu for udgar, koorma for unmeelana, krukala for kshudha, devadatta for jrumbhana, dhananjay for poshana) whereas ayurveda describes different abnormal conditions caused by alone of five types of vata & in combination with pitta & kapha, observes Kenneth G Zysk28 Prana & respiratory phenomenon played key role in development

25

03 Review of literature of yoga & its ecstasy practicises in later orthodox upanishada & texts on yoga. However medical physiology of prana & body winds split from upanishadic tradition &developed into a separate discipline. K G Zysk observes that this was probably due to intimate partnership between medicine & heterodox ascetic tradition such as Buddhism whose followers utilized ascetic techniques from upanishada & contributed to early codification of medical doctorine.29

Prana , apana , vyana, udana & samana are five prana vrutti. Yoga shastra is having mention of jaya over samana & udana only & not prana, vyana & apana. In phalashruti of rudropanishad again there is mention of prana shchme , vyana shchme, apana shchme & again samana n udana are not mentioned observes kolhatkar Keshav Krushnaji. He remarks that prana & apana & vyana are less in control of humans in comparison with udana & samana.30

For both a healthy life and the practice of meditation, Vedanta says that it is very useful, or essential that this level of our being be trained, regulated, and directed, so that it flows smoothly. In meditation, we become aware of Pranamaya kosha, explore it, and then go inward, to and through the other koshas.31

2) Meaning & Significance of the term ‘Prana’

Prana has remained fundamental in Ayurvedic theories. The term is used for variety of elements as the phenomenon of life depends on many of them. Etymology: Grammatically the word is made with upasarga of ‗ ‘

33 applied to dhatu (root word)अन 32& stands for to breath, to respire, to move, to go. Prefix has meanings before, forward, in front of, forth, filling, fulfilling. When used as an adjective it means excessively/ very/

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03 Review of literature much. Dictionary meaning of 35 is Breath in, inhale, the breath of life, breath, respiration, spirit, vitality, life.

Ayurvedic literature contains numerous references underlining importance of prana. According to Parashar rishi, nabhi is first organ to be developed in fetus. Simply because nabhi is the place for ‗prana’ along with bodily ushma.36 The verse implies association of agni & prana & also it highlights prana as a precursor. According to Charakacharya, while treating ‗aavruta vata‘, vaidya shall particularly take care of ‗prana’ & ‗udana’ as ‗life‘ depends on prana & ‗bala’ depends on udana.37 This is why the definition of genuine vaidya is ‗pranabhisara vaidya’. A physician dully engaged in the study of the science of medicine, in mastering their actual implications, in the right application of the therapy & having practical experience is known as savior of prana i.e. ‗pranabhisara’, says Charaka.38 According to another definition from same classic, there are 10 sites as resorts of life i.e. prana, called as pranayatana including two temples, three vital organs (hrudaya, basti, shira), kantha, rakta, shukra, ojas & guda. The wise physician who is well acquainted with these pranayatana, the internal as well external factors like senses, intelligence, soul, causes of disease, their recovery & signs & symptoms of disease is known as ‗pranabhisara vaidya’ i.e. savior of life.39 At another place referring to physician of kings, there is again mention of ‗prana‘. The vaidya well versed with specific features of all diseases, principles of their treatments & properties of all medications is entitled to be royal physician.40 The desire for life is said to be the first of all. Charakacharya quotes that, ‗Out of all these desires, one should give priority to the desire for longevity as with the end of life there is end of everything. This longevity can be achieved by observance of the rules meant for healthy persons & by non negligence in treatment of diseases if they occur. Thus following prescribed course one is able to preserve his life & can live long.41 While commenting on this verse both of Chakrapani

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& Yogindranath Sen opine that ‗prana’ is nothing but life. Chakrapani recommend ‗prananupalana’ for same. Yogindranath Sen enlist them as swasthavrutta palana, avoiding vegadharana, sahasavarjana etc. ‗Jivita’ is synonymous to prana is a singular term but resides in many places, says chakrapani.42

Term prana is many times used as synonymous with ‗vayu’ & not merely for a single kind of vayu. Charakacharya have mentioned that, ‗Dehagni is responsible for life, varna (colour) strength, health, enthusiasm, plumpness, complexion, ojas, tejas, agni & prana.‘43 Chakrapani while commenting on same clarifies that term ‗prana’ is inclusive of all of its five kinds. This is why the term is used in ‗bahuvachananta’.44

Charakacharya mentions that milk is wholesome & shodhana & shamana for all pranabhruta. i.e. Living persons.45 Chakrapani& Yogindranath sen clarifies that by the term ‗pranabhruta’ only jarayuja are to be considered. It means that ayurvedic concept of prana is applicable to ‗jarayuja prani.‘46

Thus term prana is mainly used as ‗synonymous to vayu’, as a ‗type of vayu’ & as a subtle vitality element i.e. ‗subtle prana’. In agrya samgraha Charakacharya quotes that, ‗vayu’ is agrya among bodily elements those can be termed as ‗prana’.47

3) Prana Vayu

Dosha is a unique concept of Ayurvedic sharir. Apart from linear structure-function approach, ayurveda has summarized all nonlinear bodily actions & phenomenons in three bioenergetic principles labeled as dosha. The factor which is not only capable of vitiation but also vitiating other entities of body is called as dosha. V V Subraniyam Shastri have listed body functions as chemical, osmotic, electrical, mechanical,

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03 Review of literature regulatory functions & have summarized them as correlative, substantive & generative. Vata, pitta & kapha are responsible for these three groups of functions respectively.48 Tridosha are often seen interpreted in context with greek concept of humors. However Patwardhan Kishor has reported that Tridosha is not simply a ―humoral theory‖; but, it is based on a considerably precise understanding of homeostatic principles.49 Scientists are in their attempts towards fullest understanding & modern interpretations of dosha. The researches are still in an evolving phase with regard to approaches and methodologies, the trends are not easily evaluable at this stage. Recently pharmacogenomics and biostatistical approaches have been used to investigate the scientific basis of the three ―Dosha‖ theories.50,51 Equilibrium of these three dosha leads to healthy status of body & vice versa. Homeostasis is the contemporary term for this balance in western biomedical view point.

Grammatical derivation of vata: Grammatically this technical term vata is derived in two ways. The basic ‗verb root‘ is ‗Va’ which means ‘Gati gandhanayoh’ (su.su 21/5).52 With the application of ‗tan’ pratyaya (suffix) and expelling ‗n’ pratyaya leads to the term Vata. The application of ‗kta’ pratyaya to the same verb root i.e. ‗Va’ leads to the word vata, which has the same meaning.

The term vata with its original root and meanings can be analysed as ‗tatra va gati gandhanayoh iti dhatu’. The verb root 'Va' means Gati and Gandhana. Prapti & Jnana (Gati Praptijnanamithyarthantarum (Panini)) are the two interpretations of the term gati. Prapti means to acquire, to attain & Jnana means to know, to sense. The term 'Gati' is also interpreted as 'Gamana' or Cesta. However gati implies momentum of bodily bhavapadartha & not only movement of it. Gandhana indicates to become conscious of or 'to enlighten' Meanings of gandhana include Utsaha (to enthuse), Prakasana (enlighten), Soocana (inform against),

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Gandhana(initiate) & Prerana (excite). Hence it can be said that Vata is the biological force which recognize, stimulate and regulate all the activities in the body.

Uniqueness of vata:

Due to the three important properties, Asamghata (Incorporeal), Anavasthita (Unstable), Anasadhya (Inaccessible) Vata is entirely different from other doshas.53 Two elements, Vayu and Akasa constitute Vata. Hence it is super sensuous, invisible, so it cannot be perceived, but it is tactile and can be recognized by its functions. Pitta and Kapha have appendages and relatively compact in nature. On the contrary, Vata is incorporeal (Avayavasamghatarahita). It can be termed as rarified in nature. The Vata is Anavasthita too. These two properties are due to its composition i.e. predominancy of Akasa and Vayu dhatu.54 Indu clarifies that here term dhatu signifies shakti swaroopatwa of Akasa and Vayu.55 Both of them are incorporeal (Amoorta). Calatva and Apratighatatva are characteristics of Vayu and Akasa perceptible by the tactile sense organ.56

Anavasthita is due to Cala Guna of Vata. It is also reported to be 'Seeghra' i.e. Swift57, Asukari (instantaneous action) & Mahuscari (Rhythmic movement).58 It is because of its fundamental quality of Rajas, inconsistent, instantaneous in action. Owing to its incorporeal nature and instability, Vata is Anasadhya (inaccessible) also. It is in regard to its functional and physical attributes, but more relevant regarding the therapeutic aspect. All these cardinal features make ‘Vata Acintyaveerya’ and ‗Dosanam Netanam’, concludes Dalhana59 & Gayadasa60 while commenting on su. Ni. 1/8.61

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Thus Vata is a physical matter with a lot of energy capable of conducting most of physiological functions in the body. Prana vata is considered as first type/swaroopa of vata dosha. Actions of prana vata are related with these guna.

Prana vayu sthana & karma:

In opinion of Charaka, Prana vayu is located at moordha (head), ura(chest), kantha (throat), aasya(mouth) & nasika(nose). It is responsible for stheevana (spitting), kshawathu (sneezing), udgara (belching), shwasa (respiratory phenomenon) & aahar karma (deglutition of food).62

Vagbhata has explained similar views. According to him, prana vayu resides at moordha & moves through chest & throat. It is responsible for noble function of dharana of Buddhi, hrudaya, chitta & indriya.63 Acharya Hemadri has clarified that moordha is avasthiti sthanam i.e. residential site of prana & ura & kantha are vicharana sthanam i.e. place for movement.64

With a marked difference Sushratacharya believes that, vayu which moves in mouth is called as prana vayu. It is responsible for dharana of deha. Prana facilitates entry of food in aamashaya & is also responsible for nobel function of avalambana of prana i.e. vital element of body.65 Dalhana adds that Moordha, kantha, nasika are too site of prana vata. Dalhana further explains that avalambana of prana is nothing but avalambana of 12 elements quoted as prana (agni, soma etc). Avalambana is empowering the same for its own physiological functioning. If this phenomenon of avalambana is affected, individual even may lead to death.66

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In view of Vruddha vagbhata, Prana resides at moordha & moves in ura & kantha. It is responsible for dharana of buddhi, indriya, hrudaya mana, dhamani. Also It is responsible for stheevana (spitting), kshawathu (sneezing), udgara (belching), shwasa (respiratory phenomenon) & aahar karma (deglutition of food)67.

Dhamani dharana as function of prana, implies all nervous operations. V V Subraniyam Shastri in his book,‘tridosha theory‘ explores term hrudaya as any organ where act of receiving, giving away & moving is carried upon. This criterion is fulfilled by thoracic heart, lungs & central nervous system.68 Instead of considering buddhi & hrudaya as separate terms G. R. Paranjape has considered ‗Buddhi-hrudaya’ as a sole term & has considered brain in same regards.69

Prana dushti: Vagbhatacharya has explained specific dushti hetu for all vata types. According to him Prana vayu gets vitiated because of Raukshya, Vyayama, Langhana, Ati ahara, Abhighat, Adhw & Vega udirana.70

4) Pranavaha srotas

Srotas is a unique consideration in Ayurvedic sharir. Srotas are the body channels through which there is transport of responding nutrients. Charaka claims that purusha is made up of srotasa only. Modern biomedicine has given importance to organs, whereas ayurveda considers Organs as moolasthana of srotas. The vitiation, depletion and maintenance of body structures are made possible by these srotas only. Charaka & Sushruta both compendium have explained srotasa in detail. Pranavaha, annavaha & udakavaha srotas are for intake and purishavaha, swedavaha & mootravaha srotasa are for excretion whereas seven dhatu srotas maintain body. There cannot be one to one

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03 Review of literature correlation for concept of srotas in western biomedicines‘ viewpoint. Concept of srotas is distinctly different and cannot be understood by conventional modern biology & its reductionist approach of classical Newtonian Physics reports Singh R H. According to him concept of srotas is all inclusive of ‗Membrane biology‘, ‗receptor biology‘ & ‗the quantum field‘.71

‗Prana’ is not only body element but also aatma guna.72 Chakrapani has clarified prana & apana as uchwasa & nishwasa.73 Charaka has quoted prerana & dharana of prana & apana as aatmaja bhava of garbha.74 Owing to importance of process of respiration prana is considered as aatmaj bhava as well as aatma guna. Metabolism of prana element is carried out in pranavaha srotas.

Moolasthana: Charakacharya considers hrudaya & mahasrotas as moolasthana of pranavaha srotas & quotes its symptoms of vitiation as Atee shrushtam shwasanam (too long respiration), Atee badham shwasanam (restricted respiration), Kupitam shwasanam (agitated respiration), alpalpam shwasanam (shallow respiration), abheekshana shwasanam (increased respiration), Sashabda shwasanam (stretrous respiration), Sashoola shwasanam (painful respiration).75

In opinion of Chakrapani, the word prana stands for the particular vayu type named prana. Although dhamani itself is sthana for vayu ; ‗pranavaha srotas’ is particularly for prana vayu.76 In opinion of Gangadhara, term ‗hrudaya’ shall be understood as ‗vaksha’77 i.e. whole cardiopulmonary apparatus occupying the whole chest. Mahasrotas is ‗mahachhidram mahasaranam’ i.e. alimentary canal.

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In opinion of Sushrutacharya, Hrudaya and rasavahi dhamani are moolasthana of pranavaha srotas. Aakroshana (loud grooming), vinamana (thoracic cavity deformity), mohana (loss of consciousness), bhramana (illusion/giddiness), vepana(tremors), marana (death) are symptoms of pranavaha srotodushti according to sushruta samhita78 as explored by dalhana.79 The ‗rasavahi dhamani’ is considered as moolasthana of pranavaha srotas. This itself implies that dhamani originating from hrudaya carry prana as well as rasa simultaneously. It refers to arterial tree only.It is said that "mulamiti prabhav sthanam" means that moolasthana of srotas are originating places for that particular body element. It is the blood in arteries arising from heart (left ventricle) are full of nutrious elements as well as oxygen.

Consideration of ‘mahasrotas’ as a ‘moolasthana of pranavaha srotas’: Mahasrotas as moolasthana of pranavaha srotas is very praiseworthy citation as the classic (Charaka Samhita) belongs to school of physicians. Mahasrotas is place of jatharagni, place for process of awasthapaka, place for udirana of doshapachana, itself a abhyantar roga marga and a body channel via which vamana, virechana & basti are done.

Opinions of contemporary scholars & scientists on srotomoola:

Prasad KSR has interpreted ‗Rasavahi dhamani’ as pulmonary vessels.80 Alapatti vinod kumar et.al. have attempted to justify moolasthana. In their view point two centers each mentioned as moolasthan in context of one srotas, primarily controls the activities of their corresponding srotas only. But there might be a super or unique controller who controls moolasthan of all srotas e.g. in rela-tion to rasavaha srotas, hrudaya and dasha- dhamani are local controllers and not super controllers.

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Mahasrotas is the basic substratum for all vital management procedures in the ayurvedic line of treatment. In disease of any srotas it is impossible to complete shodhan chikitsa as well as shaman chikitsa without support of mahasrotas. In this regard, mahasrotas is justified as unique or super controller of all srotas.81 Verma Vandana has reported that Pranavaha srotas should not be studied only with the correlation of respiratory system but it must be studied in context to other major systems (srotas) like nervous system (Regulation of respiration), cardiovascular system (Transportation of prana i.e. O2) and alimentary canal (as haemoglobin is main carrier of O2 and for synthesis of haemoglobin required nutrients are obtained through GIT).82 Kamath Nagraj et. al. have reported that Pranavaha Sroto mula is Hrudhaya and Mahasrotas. Prana in this context can be considered as the Vayu and Anna. Vayu is sarvadeha-chara and is responsible for all the functions especially the Vyana Vata which is mainly situated in the Hrudhaya and moves throughout the body and is responsible for all the functions. Anna is responsible for the formation of Dosha, nutrition to Dhatu and formation of the Mala. Dosha, Dhatu, Mala are the basis for the body and the Anna is ingested, Digested, Absorbed in Mahasrotus and excreted out of the body through Maha-srotus.83 Vd. Nanal Vilas has opined that right side of heart that deals with receiving oxygen rich blood is pranavaha srotas. And as left side of heart deals with nutrient rich blood it can be called as rasavaha srotas.84 In view of Patwardhan Kishor the neuronal control of respiration (its rate and rhythm) & gaseous exchange fall under the purview of Prana Vayu and Pranavaha Srotas. Whereas the chemical control of respiration, acid-base balance, and, water and electrolyte balance fall under the purview of Udakavaha Srotas.85 Process of Respiration in ayurved: A well-known reference from Sharangadhara Samhita is considered as depiction of respiration in ayurveda. According to aacharya

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Sharangadhara, prana vayu which resides at nabhi touches the heart & comes out from kantha for drinking vishnupadamruta. Here Aadhmalla in his commentary opines that Hritkamalantaram iti Hritkamalasya Abhyantaram. Some Scholars interpret it like the deoxygenated blood from vein reaches inside the right auricle through both the vena cava.86 After drinking piyusha (nectar/oxygen) it again enters in body very rapidly. It provides strength to body & also empowers the jatharagni.87

Dr. Yogesh Chandra Mishra has elaborated that,`Lord Vishnu is supposed to be protector of the universe. The words swarga & naraka have been used for higher & lower senses in various references. Vishnupadamruta should be compared with pure air having a balanced composition of 21% oxygen & 70% nitrogen gases. The word ambar piyusha has also been used for this highly purified air & not for the oxygen only as 100% oxygen may prove fatal for human being.‘88

Rate of respiration: Shatapatha brahmana has described that number of respirations in one aahoratra. Shata shatani means 10,000 & shatenashtau means 800. Thus 10800 prana & apana happen in 24 hours. 21600 in 24 hours means 900 per hour & 15 per minute.89

Role of nabhi in sharangadhara’s respiration: Nabhi is considered as Mulasthana of Sira. Meaning of the word Nabhi is Bandhana. Acharya Sushruta described it as Sirabhihi Aavrittai Nabhi Chakranabhi eva Arakai (Su. Sha. 7/8) It means that union of Sira takes place around this region. Mali Pawan has elaborated it as, ‗Formation of inferior vena cava takes place at the umbilical region. It is a major vein which drains deoxygenated (impure) blood from periphery which may be considered as Sirabandhana or Union of Sira at Nabhi. Prana pavana is

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03 Review of literature related with functions of Prana Vayu. Inhalation i.e. (Nishvasa is a function performed by Prana Vayu.) During inhalation movement of abdominal muscle can be visible easily. Acharya Sharangadhara may be described these movements in relation to Nabhi. During this process of Pranavayu i.e. inspiration, negative pressure is created in thoracic cage, movement of ribs takes place in upward and outward direction. Due to negative pressure created in thorax venous blood from inferior vena cava as well as superior vena cava drained in thorax and finally it opens into right auricle.‘56

‘Role of nabhi/ agni in respiration’: Role of nabhi in respiration‘ is needed to be explored in light of classical Ayurvedic physiology. Nabhi is considered as sadyapranahara marma & thus a site for vitality element. Nabhi is an anatomical landmark for grahani & jatharagni. Thirteen kinds of agni i.e. dhatwagni & bhootagni ultimately depend on jatharagni. The Nobel function of agni is to convert panchabhautik food in a bodily form I.e. sajatiya form. Inhaled air is again needed to be converted in body friendly form. It is important to note here that fuffusa90 i.e. lungs (the organ for gaseous exchange) are made up of rakta fena & hrudaya91 i.e. heart (the organ meant for circulation) is made up from quality derivatives of rakta & kapha. It is important to note that, rakta is a dhatu that gives aashraya to pitta & it‘s all metabolic activities.

Even according to western concepts, respiration is related with removal of waste biochemical entities. It is also related with thermoregulation. And thus can be viewed in ayurvedic context of agni. Thus physiology of respiration in ayurveda is closely related with rakta- pitta- agni & nabhi in turn. Present study deals with physiological interrelationship of hrudaya –prana & agni.

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Brief History & Review of respiration in western biomedicine:

History of physiology of breathing dates back to the 17th century. Hippocrates father of modern medicine has ―counted air as an instrument of the body,‖ just as food eaten was.92 Afterwards, Robert Boyle, primarily a physicist, revealed principles of weight and pressure of the air. In 1660, he demonstrated that air was necessary to both life and combustion by placing a candle and a small animal in a vessel, and evacuation the air.93 Later Robert Hooke explained that after the thorax of a dog had been widely opened, life could be prolonged indefinitely by artificial respiration. This proved that the whole of the essential business of respiration takes place in the lungs.94 Hooke also noticed that the blood as it entered the lungs was dark coloured, but as soon it left, it turned bright red, as long as artificial respiration was kept up. When this was stopped, the blood pulmonary veins and left heart became dark and venous.95

Later the detailed role of lungs in homeostasis was explored. The respiratory system contributes in a variety of homeostatic processes, and the two most important of these are maintaining pH and regulating gas exchange. If blood gas composition, especially of carbon dioxide, moves outside the homeostatic range, the change is detected by chemoreceptors and respiratory responses are promoted which change alveolar ventilation, alter alveolar gas composition and so reverse the change.

Parallely biochemistry of this essential element oxygen was explored. Although highly toxic at higher concentrations it is a very essential element. The word oxygen is originated from greek stems oxys i.e. ―acid‖ and gennan i.e. to form or generate‖. Thus literally meaning, ―acid former‖. ATP is required in most energy consuming steps in intermediary

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03 Review of literature metabolism as well as in maintaining proper ion gradients in cells and extracellular fluids. Aerobic metabolism provides the energy needed for ATP synthesis. With numerous regulatory mechanisms maintenance of oxygen levels in tissues is maintained. Oxygen reduction takes place step by step in mitochondria and final products are water and carbon dioxide. Carbon dioxide crosses easily across cell membranes, and travels in the blood from the tissues to the lungs where it is exhaled. Hemoglobin, the main molecule in red blood cells, binds both of them oxygen and carbon dioxide.

Carbon dioxide is a metabolic waste product in organisms that obtain energy from breaking down sugars, fats and amino acids with oxygen as part of their metabolism. In aerobic cell respiration, when oxygen is present, most metabolism will undergo two more steps after glycolysis— Krebs Cycle and Electron Transport, to produce their ATP. In eukaryotes, these processes occur in the mitochondria, while in prokaryotes they occur in the cytoplasm. In Krebs cycle the carbon dioxide is released as an end (and thus waste) product.

5) Prana-Agni-Aahar

Prana has got very close relationship with agni. It can be summarized under following subtitles: a) Prana-Agni interdependence b) Aahara pranayana & prana vayu c) Ahara: as bahya prana

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1) Prana-Agni interdependence

Charaka states that, ayu (life), varna & prabha (luster & complexion), bala, utsah (enthusiasm), swasthya (health), upachya, oja, teja & prana all depend on dehagni.96 Chakrapani clarifies here term prana is inclusive of all five types of prana & thus is synonymous with vata dosha itself.97 At another place, Charakacharya quotes that person‘s bala, aarogya, aayu & prana depend of agni. By fuel of anna & paana, the agni becomes prajwalit or manda.98 While commenting on this verse Chakrapani clarifies that here term prana denotes vayu as well as dasha pranayatana i.e. sookshma/subtle prana99. Thus interestingly in context of interdependence on ‗prana-agni’, Chakrapani gives importance to both, ‗prana vayu’ as well ‗subtle prana’, or ‗aashrayee (prana) & ‗aashaya’ (pranayatana).

Charakacharya has quoted that ‗peya’ recommended in samsarjana krama, for mandagni individual & for langhita individual, results in enhancement of agni and prana. The concomitant enhancement of prana & agni in said verse underlines their close relationship.100 ‗Manda’ is able to manifest its function of ‗prandharana’, because of its deepana karma & laghu attribute.101 Chakrapani clearly explains that manda is pranadharana, because it‘s deepana karma & laghu attribute empowers agni.102

Thus it is clear that, for ably doing the karma of pranadharana, a dravya/guna / karma must be friendly with agni. In similar context treatment modality of ‗Langhana’ is pranadharana. In jwara chikitsa, langhana is recommended. Here again Charaka warns to do langhana very aptly as excess of langhana may be harmful for prana.103 Chakrapani explains prana virodhi as bala virodhi.104

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Thus Prana which resides in its aashraya & the one which is synonymous with bala (vigour, immunity) has interdependence with agni.

2) Aahar pranayana & prana vayu:

Vagbhatacharya quotes that timely taken food is brought in koshtha by prana vayu & is made mrudu by sneha.105 He has echoed charakacharya‘s view.106 This aahara pranayana of ahara is done by anuloma gati of prana.107 Sushrutacharya interestingly has quoted mukha as important site of prana vata instead of shira.108 Gayadasa has taken this difference for discussion. Making a question that, although hrudaya is quoted as prime site of prana vayu why is mouth considered as sthana of prana. It is by mouth only one can get aahar & thus avalambana of prana & hrudaya is made possible, he explains. The sole & important purpose of aahara is again pranadharana. Here by term prana twelve factors agni, soma etc are to be considered. It is mouth only by which one can get aahar & thus avalambana of prana & hrudaya is made possible. Gayadasa further explains that pranavalambana further results in hrudayavalambana. 109

3) Ahara: as bahya prana

Charakacharya quotes that ‗Anna (food) is ‗prana’ of all living animals. All have pravrutti towards it i.e. anna. Varnaprasad, swara, deergha jivana, pratibha, sukh, tushti, pushti, sharir bala & intelligence are derived from anna.‘110 The food having appropriate rasa, vrana & gandha ingested by apt method of aahar visheshayatana is useful for prana rakshana.111 Commentator Chakrapani explains that, ‗ahara is hetu for sustaince of life, as ghrut is for aayu. It can be well understood by pratyaksha

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pramana itself that anna is prana. Ahara taken following the rules of diet i.e. aaharvidhividhana results in prananupalan. If diet is not taken there is loss of prana. Pranana is function of aahara is again understood by anumana. Agni depends on diet itself. Agni in a balanced state is hetu for keeping prana in balanced state. This is why anna is hetu for prana.‘112

Sushrutacharya very clearly quotes that, ‗Bahya prana is not unfriendly with aabhyantar prana, because sharir dharana is done by panchabhautika bahya prana.‘113 Dalhana has further explored that, ‗Abhyantar prana is nothing but ‗bala’ that can be examined by bhar aaharana shakti. Prana is a shakti lakshana and depends on sharir guna like dardhya. Such sharir guna depend on upachaya which is in turn is done by aahara. Aabhyantar prana is nothing but agni, soma, vayu, satwa, raja tama, panchendriya & bhutatma. Bahya prana includes aagneya, saumya & vayaviya dravya, five attributes like shabda, sparsha, roopa, rasa, gandha & diwas ratri. The appropriate intake of bahya prana results in sharir dharana. Commentator Lakshamana adds that aaahara with its preenana attribute leads to prana dharana.114

6) Subtle Prana

Along with prana vayu (a kind of vayu), term prana is also referred as a subtle vitality element too. This subtle prana is said to be located at pranayatana (10 special sites of prana). It is also resided at marmas (vital points), along with rakta, particularly in tri marma (Three vital organs) & at nabhi. So far as nature of subtle prana is considered many references show equivalence in subtle prana & bala. There is also a unique conceptualization of of twelve prana in Sushruta Samhita. Thus the subject can be reviewed under following subtitles.

1) Marma & Prana 2) Pranayatana & Prana

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3) Rakta & Prana 4) Trimarma & Prana 5) Equivalence of Prana & Bala 6) Concept of twelve prana

1) Marma & Prana: Charakacharya has quoted that marma gives aashraya to subtle prana as the vitality element prana itself resides in marma only.115 Marmas are sites for prana in particular specifies Sushruta & elaborates them as sites of sannipata (adjoining area) of mamsa, sira, snayu, asthi, sandhi.116

According to Sushrutacharya, ‘Sadyapranahara marma are agni dominant. Vitiation of such marma lead to death instantaneously as ksheena agni speedily diminishes prana. Kalantara pranahara marma are agni-soma dominant. As here agni principle is associated with soma principle, process of pranaharana occurs slowly. Vaikalyakara marma are soma dominant. Soma guna is capable of taking care of subtle prana owing to its sthira & sheeta attributes.‘117 Thus it is important to note that ksheena agni rapidly diminishes subtle prana whereas sthira & soma attribute ably preserves/ nurtures subtle prana i.e. avalambana of prana.

In siddhi sthana Charakacharya has mentioned that, ‗In protection of marmas vayu needs to be carefully kept in equilibrium. because vayu is responsible for excitation of kapha & pitta and subtle prana also depends on vayu. This vayu is best treated by basti, therefore there is no other than basti therapy which can safeguard the marmas/pranayatana.‘118 In commentary Chakrapani has elaborated that avikruta vayu is hetu for prana & jivana whereas vikruta vayu is pranaghataka.119

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2) Pranayatana & Prana:

Certain elements or substances in the body, and systems related to specific organs, are noted having close relation with the prana. Such locations are termed as Pranayatana. Any trauma to them can terminate in crisis of subtle prana & may prove fatal. Charakacharya has enlisted120 them as shankha, trimarma, kantha,rakta,shukra, ojas, gudam & replaced shankha by mamsa in a reference from sharir sthana.121 Sushruta has enlisted them like shira, rasanabandhana, kantha, rakta, hrudaya, nabhi, basti, shukra, oja, gudam.122 Ashtang hrudaya has quoted same list.123

Sankha marma: The Sankha word indicates couch shell which has a conical shape. It is an anatomical space between parietal, frontal, maximal portion of skull and the ears. Sankha marma is situated above the end of eyebrow and between ear and forehead. This is an asthi marma with a length of 1 cm (1/2 fingers width).

Hrudaya marma : It is a Sira marma situated in thorax in between the two breasts. It measures to a length of 4 Finger widths (4-5 cms). Relationship of prana-hrudaya is explained further.

Basti marma: Basti is generally refereed to urinary bladder. The Basti marma is type of snayu marma located inside the pelvic cavity. It has an area of 4 Finger Width (4-6 cms). Relationship of prana-basti is explained further.

Guda Marma: This is a Mamsa marma. Guda is the organ responsible for the evacuation of stool and Flatus organ guda is very much co-relatable to the rectum. The marma is said to of 4-5 cms in length (Four Finger Width).

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Kantha: It is Sadyapranahara marma. Throat is considered as sira marma.

Shukra: It includes reproductive elements / semen. As the distant dhatu are quality derivatives (as per Ksheerdadhi nyaya) shukra is an important dhatu. Prana resides in it.

Ojas: It is the vital essence of all dhatu & thus is site for prana. Charaka has discussed role of ojus role in maintaince of health in sutrasthana. ‗It is the ojus that keeps all beings refreshed. There can be no life without ojus. Ojus marks the beginning of the formation of embryo. It is the nourishing fluid from the embryo. It enters the heart right at the stage of formation of the later. Loss of ojus amounts to the loss of life itself. Ojus sustains the life & is located in the heart. It constitutes essence of all tissue elements‘, says Charaka124.

Walton KG et al have stated that body phenomena for recovering and maintaining optimal function of steroidal systems can be correlated with ojus.125 Concept of ojus is seen intimately related with concept of immunology in contemporary scientific literature. However scientists Gangadharan GG & Manohar Ram have made emphasis on wholistic Ayurvedic approach & reported that one must understand that, the nature of Ojas will differ from person to person depending on constitution, Agni, Satva and so on.126 Thus ojus the essence of all body tissues is a site of subtle prana.

Rakta: Prana-Rakta relationship is explained separately

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Mamsa: Mamsa dhatu is an inclusive term for skin & muscular tissues. Prana resides in it. Vruddha Vagbhata has named 6th layer of twacha as, ‗Pranadhara twak’.127

Nabhi: Prana-nabhi relationship is explained separately

Rasana bandhana: Jivha bandhana is considered as site of prana.The sublingual route is extensively used when rapid onset of action is desired as liver is bypassed in this route. Its membrane is more permeable than the buccal (cheek) area, which in turn is more permeable than the palatal (roof of the mouth) area. The portion of drug absorbed through the sublingual blood vessels bypasses the hepatic first pass metabolic processes giving acceptable bioavailability.128

3) Rakta-Prana Relationship

Vishuddha rakta is said to be responsible for bala, varna, sukha & aayu as prana follows rakta, quotes Charaka.129 Both of them Chakrapani130 & Gangadhara131 have clarified same as prana cannot reside without rakta, whereas rakta is of no use if it do not contain prana. The application of this concept can be seen in chapter of mada-moorcha-sanyasa. Acharya have specified that accumulation of dosha in raktavaha srotas leads to Moorcchha.132

That is why Sushrutacharya quotes that Roodhira is moola of all body. Hence a physician must guard rakta dhatu as jeeva resides in rakta.133Dalhanacharya134 clarifies the term moola as a causative factor for utpatti, sthiti & pralaya of sharir & the driving force for dharana. Whereas Chakrapani in bhanumati commentary term moola signifies genesis of next mamsadi dhatu.135 Bhavamishra too implies same in a verse that, ‗jeeva or life principle resides particularly in shukra, rakta

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03 Review of literature dhatu & mala. If there is depletion of these three, sharir turns ksheena.‘136

4) Tri marma (Three vital organs) & Prana:

Hrudaya, Moordha, Basti are special sites of prana and physician shall take care of yapan of these organs says Charaka.137

a) Basti & prana:

While explaining anatomy of basti, acharya Sushruta describe that it is alike allaba (pitcher gourd) and well supported by sira & snayu. It is receptacle of mala & serves as site of prana i.e. life element.138 Dalhana further clarifies that basti is place of prana simply means place for twelve prana elements viz. agni, soma etc.139

b) Nabhi & Prana:

Sushratacharya quotes that Prana is resided at nabhi. Nabhi is the seat of all sira. Nabhi is surrounded by sira very similar to axle hole being surrounded by spokes.140 Spokes in said example is resembled with sira in human body.141

Some scholars have believed that nabhi as a pranayatana is nothing but heart. Because Charakacharya once considered Hrudaya and Nabhi both among ten Prana (Ca. Sha 7/9) and on second occasion, has not considered Nabhi among the ten sites of Prana along with Hrudaya (Ca. Su. 29/3). Rapolu Sunil Buchiramulu & Piyush Kumar Tripathi has opined that by the term "Nabhi" heart should be considered here.142 It has been explained by Acaryas that life resides in Nabhi. So far as context of present study is concerned, nabhi is place of prana & point of ignition of respiration. Nabhi is place for sira as well as agni. &

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03 Review of literature hence by term ‗nabhi’, umbilicus can be justified. Present hypothesis is for explaining the same relationship of agni/nabhi, Prana & Hrudaya. c) Hrudaya-Prana

Hrudaya is the most important site of prana. Sharir rasa sneha resides in hrudaya where prana resides. If it gets depleted, there is death, says Charakacharya.143 As the spokes of the wheel are attached to the center i.e. nabhi, similarly ten vessels, prana vayu, apana vayu, manas, buddhi, consciousness, & mahabhoota are attached to the heart.144 Chakrapani clarifies that, ‗Prana vayu & apana vayu referred here are for ucchwas (expiration) & nishwas (inspiration) respectively. According to some scholars, these two terms represent two verities of vata dosha. They explain that although apana vayu is located in genital organs & pelvis still its functions are controlled by heart.145 Prananubandha is considered as rasaja bhava.146 Thus implies relationship of prana & rasa, wherein hrudaya is moolasthana of rasavaha srotas. Hrudaya, where are attached pranavaha dhamani is made up from quality portions of kapha & rakta says Sushruta.147

Term ‗hrudaya’ in context with pranayatana can be explored more. While explaining samprapti of sanyasa, Charaka quotes that acutely aggravated dosha affect the speech, manas & sharir enter the pranayatana, weaken the individual & bring the absolute loss of consciousness in him.148 Vagbhatacharya has quoted same samprapti using same term as ‗pranayatana.‘149

Chakrapani150 & Arundatta151 both of them in their commentaries have made clear that in this context term pranayatana is nothing but hrudaya.

Interpretation of term ‗Hrudaya’ is a widely debated topic in ayurved. As reviewed previously Paranjape GR have opined that hrudaya as a

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03 Review of literature pranayatana is nothing but brain. Parishadyam Shabdarth sahriram a proceeding publication comprises the bouquet of opinions. Mainly term hrudaya is used for heart/brain/cardiac region/aamashaya. Pt Hariprapanna sharmaji & Dr. ghanekar consider heart as hrudaya, whereas Gannath Sen believed brain as hrudaya. Dr banerjee support opinion of Dr Godbole shastri & consider all of six among heart, lung, brain, xiphoid cartilage, placenta & plantar surface as hrudaya. Editor of Parishadyam shabdartha shariram vd. Gaud damodar sharma has concluded that ‗Perception of brain as heart can be appropriate in the science of yoga what Bhelacharya has mentioned as urdhwa hrudaya. But In ayurveda it is more appropriate to consider heart as hrudaya.‘152 Dr. JLN Sastry, Dr. Nisteswar K have reported that ‗….From the beginning there was a debate among ayurvedic scholars whether or not to give primary importance to heart. When the amphibian experiments proved that heart can continue its function even if brain is removed, then the importance of heart was more realized.‘153 Interestingly in compilation of sadyapranahara marmas, hrudaya is considered as separate along with other mention of shira.154

But again it is Charaka to quote that indriyavaha srotas & pranavaha srotas are in connection with Shira as like rays are connected with sun.155 Atharvaveda attempts to associate hrudaya & moordha. Vedic rishi described that the atharva i.e. god has interlinked hrudaya & moordha. Also the vayu that resides in upper part of moordha, is responsible for respiration & activities.156 Thus in present picture both of heart & brain are relevant so for as context of prana is considered.

5) Nature of Subtle prana & its equivalence with bala:

‗Prana’ is a vitality element. Ayu depends on it. In fact Charaka quotes that ‗Ayu’ is called as ‗anubandha’, where being united with prana is

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03 Review of literature lakshana of same.157 Chakrapani has clarified same as union of prana vayu itself.158

The life denotes life energy & a life with bala. Interestingly plenty of references quote that prana is equivalent with bala.

Equivalence of Prana & Bala:

Concept of bala is wholistic concept & includes entities & mechanisms behind the phenomena of sharir bala (the one is examined by vyayamshakti) & manas bala & immunity.

In Charaka Samhita sharirasthana Rasaja bhava for garbhotpatti include prananubandha.159 Commentator Chakrapani has quoted ‗Prananubandha iti balanubandha’.160 Alpapranata is poorvaroopa of jwara in both of Charaka Samhita as well as Ashtang Hrudayam. In his commentry on Charaka samhita, Chakrapani161 refers ‘Manas bala hani’ as Alpapranata in Cha. Ni. 1/33 In same context Arundatta162 refers alpa-pranata as ‗Stokabalatwam’ whereas Hemadri163 interprets it as Prano Balam while commenting on Ah. Ni. 2/7 On commenting on word balavatam, Dalhana quotes as shaktiyuktam.164 ‗Prana-kshaya’ is a factor for asadhyatwa in case of a wound in opinion of Sushruta as in su.su. 28/20. While explaining same Dalhana considers prana as equivalent of shakti lakshana bala. i.e. bala that can be expressed in terms of shakti.165 While explaining general properties of milk Sushrutacharya mentions pranada (one which provides prana) as its property. Chakrapani in his bhanumati commentary on Su.su.45/47-48 explains ‗Pranadam’ as jivitkara i.e. one resulting in longevity of life. Whereas Dalhana clarifies that action pranada is nothing but dharana (maintaince) & upachaya (nourishment) of twelve prana inclusive of agni, soma etc.166

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Thus there is a significant equivalence in concept of bala & prana.

6) Concept of twelve prana

In a unique conceptualization, Sushruta has enlisted elements agni, soma, vayu, satwa, raja, tama, five indriya & bhutatma to be considered as prana.167 Dalhana has explained that, ‗Prana the life element, is hetu for sustenance of deha. Upadan of prana i.e. factors for life principle are agni & other eleven elements. Agni is the shakti (energy) residing in five kinds of pitta, Five bhutagni & seven dhatwagni. It is also adhidevata of vak i.e. speech. Soma is again a shakti (energy) residing in rasanendriya & liquid body elements like shleshma, rasa, shukra etc. It is also adhidevata of manas i.e. mind. Vayu is nothing but the panchatma vayu. Satwa, raja, tama are nothing but components of prakruti. Indriya are five indriya and aatma is endorsed with shubhashubh karma. Agni performs its pranana karma by aahar paka etc karma. Oja & other saumya dhatu perform their pranana karma by nourishing body. Vayu performs its pranana karma by movement of dosha-dhatu-mala & ucchwas & nishwas. Satwa, raja, tama perform their pranana karma using tool of manas whereas five indriya by their own function of roopagrahan etc.‘168

7) Prana -Mana–Indriya

Prana is a basic & essential entity that it is considered as aatmaguna by Sushrutacharya.169 Here term prana indicates prana vayu clarifies Dalhana.170

It is a noble function of prana vayu to control functioning of manas & indriya. This Ayurvedic phenomenon of control of mana & indriya by prana vayu can be traced back to upanishada. There is a question asked

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03 Review of literature in first chapter of Kenopanishada. ‗What is the reason for ‗mana’ for becoming patita to vishayas & controls prana?‘171Adya Shankaracharya in his commentary ‗Shankar bhashya‘ has clarified prana as nasal one referring to prana vayu.172

Satwa, aatma, sharira are the tripod of aayu i.e. life. Ayurveda believes that aayu is inseparable & samayogavahi combination of sharira (physical body), manas (mind) indriya (sensory-motor organs) & aatman (consciousness). And thus in its true sense ayurveda is a mind-body medicine.

Manas is considered as a karan dravya along with five mahabhoota, aatma, kala & disha.173 In some cases manas is considered to synonymous to hrudaya. The commentator has equated heart with mind while commenting on word hrudya in gana prakarana.174 Association of prana with hrudaya is explained earlier. Chitta (meaning consciousness) is a synonym of manas. It indicates its inseparable allegiance with aatman. This allegiance is active in attainment of knowledge. In conditions where the manas is not attached with aatman (located in hrudaya) it is impossible to obtain the knowledge. Prana & indriya reside in uttamanga i.e. shira says charaka.175 Shira is place for indriya, indriyavaha & pranavaha srotamsi quotes Charaka.176 Late Vd. Nanal Vilas has reported the role of prana & accomplishment of desire an aatma guna. ‗Desire (iccha) is considered as first among attributes of aatma. For completing this ‗desire‘ other attributes like jnana/ vijnana (general as well specific knowledge), smruti (memory), buddhi (intellect) are brought into play. Prana vayu creates the impulse to accomplish the desire. The mana (mind) is called upon & the desire is communicated to it. Thus activated manas employs another aatmic attribute called as prayatna (effort) to relate the suitable indriya or effector organ. On the body plane necessary bodyconstituents are activated like the prana vayu,

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03 Review of literature vyan vayu, udana vayu, the rasa, rakta, effector organ (karmendriya) and thus the act is completed. If the whole operation runs its course smoothly the desire is gratified and result is pleasure, happiness & tranquility. If the process is hampered or arrested at any level it results into anger, disgust, grief, dejection, depression, withdrawal etc.‘177 Charaka relates that indriya are ruled by manas but manas is ruled by vayu.178 Hath yoga pradipika says that manas & vayu are conjoined with each other as milk & water. i.e. they are inseperable.179 Nobel functions of vayu include niyamana & prerana of manas.180 In particular prana vayu resides at moordha & moves through chest & throat. It is responsible for noble function of dharana of Buddhi, hrudaya, chitta & indriya.181 Indriyadharana is function of maintaining efficiency of all indriya by generating appropriate impulses at appropriate time. The term prana itself means that a kind of vayu capable of generating impulses those trigger off process of perception.

Vitiation of prana by manas hetu:

Manas hetu are widely quoted for genesis of various diseases. There is a reference where manas hetu are quoted for prana kshaya in particular. irshya, utkantha, bhaya, tras, krodha, shoka lead to kshayaja rajayakshma along with significant prana kshaya says charaka in context with kshayaj yakshma.182

Interestingly ‗Ahimsa’(non violence) is considered best amongst all hetus for enhancing prana principle in living individuals.183 Ahimsa leads to dharma & dharmajanya vyavahara are sthira. If one is not following dharma then, ‘apchar anusandhana janya dainya’ i.e. bhaya & stress will affect his prana principle explains Chakrapani.184 Ekatwa & anutwa are manas guna.185 Anutwa literally means minuteness. This guna helps manas to move swiftly across the body. This is made possible by sukshma guna of rasa dhatu & vayu. Rakta dhatu is inseperable with

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03 Review of literature prana. Prana & pitta (the ashrita dosha of rakta dhatu) make it convenient for manas to act. Sadhaka pitta has the role in particular.

Thus Prana serves as a linkage between sharir and aatma guna. On one hand there are manas, & more subtle metaphysical entities like mahat & ahankar while on other side, there are more gross actual body structures made up of panchamahabhoota.

8) Status of prana in a diseased condition:

Prana being an important kind of vata dosha & a vitality element, is seen in altered status in different diseased states. This subchapter deals with condition of prana in different diseased conditions.

1) Jwara:

Alpapranata is poorvaroopa of jwara, in ashtang hrudayam186 & Charaka Samhita.187 Arundatta188 comments that alpa pranata is less bala of the individual. Hemadri189 has clarified that prana is bala. Chakrapani quotes that daurbalya is indicative of sharirbala hani whereas alpapranata stands for manas bala hani.190

2) Yakshma:

Amongst four types of rajayakshma, ‗Kshyaja yakshma’ is particularly prana kshayakaraka.191

3) Udara:

Charakacharya quotes that all diseases particularly udara are manifested as aggravation of malas & because of agni dosha. If a person with suppression of agni takes polluted food, it results in indigestion which leads to dosha sanchaya. This accumulation of dosha vitiates

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03 Review of literature prana, apana & agni. It also creates obstruction to upward & downward channels.192 Chakrapani has noted that agnidosha is nothing butagni mandya itself. The term mala is inclusive of both tridosha & purisha, mootra, sweda. Accumulation of dosha results in incessant agnimandya & thus vitiates prana, apana & agni. Vitiated Vayu vitiates prana & apana as it is very possible that vayu itself vitiates a particular type of vayu.193 Accumulated dosha obstructs swedavaha & ambuvaha srotas & lead to dushti of prana, apana& agni.194

4) Arsha:

While discussing about sahaja (congenital) arsha, charakacharya quotes, ‗Right from his birth, his apana vayu gets obstructed & moves upwards & vitiates samana, vyana, prana, udana, pitta & kapha.‘195 Prana dushti is essential part of samprapti of sahaj arsha. Alpa prana is a symptom in sahaj arsha.196

5) Shwas-Hikka

In shwasa samprapti vayu located in chest after afflicting the pranavaha srotas, gets vitiated & stimulates kapha.197

Premonitory symptoms of shwasa include vilomata of prana. In opinion of Hemadri, vilomata is viparitata.198

Aanaha (constipation with flatulence), pain in sides of chest, pain in cardiac region & vilomatwa of prana vayu are its premonitory symptoms of shwasa in opinion of charaka.199 In opinion of Chakrapani, vilomatwa is paryakulatwa. Paryakulatwa is being agitated/distressed/ troubled. It

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03 Review of literature means not only reversal of prana gati but also its qualitative vitiation.200 Vilomatwa stands for reversal of direction.

Vayu along with kapha, having obstructed channels of pranavaha & ambuvaha & annavaha srotas, causes hikka. Vata in association with kapha suddenly afflicts the throat of patient who is denuded of mamsa, bala, prana & tejas & causes hiccup with exceedingly loud sound.201

Chakrapani interprets as, ‗Prana is said to be vayu at doshik level, it is also said to be teja agni (Present hypothesis states that prana depend on agni & in turn nurtures agni too) & utsaha i.e. enthusiasm which is manas bhava.‘ The commentry of Chakrapani on this sootra is a highly praiseworthy as it implies meaning of term prana at all of 3 important levels.202

6) Kasa: Vitiated Prana goes along with udana & produces sound like broken vessel of bronze & comes out of mouth with doshas. The condition is called as kasa, says Sushruta.203

Kasa symptoms includes prana kshaya as in Sushruta Samhita.204

7) Visha:

Charakacharya has mentioned specific action of the each of guna of visha. It is because of teekshna guna, visha becomes marmaghna (causes injury to marma) & because of vikasi attribute it becomes pranaghna (leading to loss of prana element). 205

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As marmas are saumya & mrudu they get vitiated by teekshna guna. The term vikasi is derived from root word kas meaning himsa i.e. violence. By implication this term means excessive violence or suppression of ojus explains Chakrapani.206

While describing visha vega of darvikara sarpa Sushrutacharya have quoted that visha in its 5th vega enters asthi & vitiates prana & agni. Parvabheda, hikka & daha are symptoms arised.207

8) Vatavyadhi:

If prana vayu is occluded by vyana vayu, there will be excessive sweating, horripilation, skin diseases & numbness in body. To such a patients virechan therapy should be administered with sneha kalpana.208

If Samana vayu is occluded by prana vayu, then there is difficulty in speech, slurring speech, and even dumbness. For such patients yapana basti & administration of sneha kalpana by four routes is recommended.209

If udana vayu is occluded by prana vayu, then there will be stiffness of head, rhinitis, dyspnea, heart diseases, & dryness of mouth. Such patients are recommended to be comforted & all treatment modalities indicated in head/neck diseases too are recommended.210

If udana vayu is occluded by prana vayu, then there will be dyspnea, pratishyaya, stiffness of head, heart diseases, & dryness of mouth211.

If prana vayu is occluded by udana vayu, then there will be loss of different bodily functions,ojus, bala & varna. Patient may even lead to death. Patient shall be slowly sprinkled with cold water, consoled & comforted.212

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If prana vayu is occluded by udana vayu, then there will be kshaya of varna, oja & bala.213

If prana vayu is occuluded by pitta, there is moorchha, bhrama, shoola, vidaha, desire for cold & vomiting of undigested food.214

Pittavruta prana lakshana include bhrama, moorchha, rooja, daha & vomiting of undigested food.215

If prana vayu is occuluded by kapha, then there will be excessive spitting, sneezing, belching, obstruction to respiration & anorexia & vomiting.216

If prana vayu is occuluded by kapha, then there will be sada, tandra, aruchi, chhardi, shtheevana, kshawathoo, udgar, obstruction to respiration & anorexia & vomiting.217

Aavarana of prana & udana vayu must be treated very carefully as life depends on prana & bala depends on udana.218 Vagbhata echoes Charaka that life depends on prana & bala is synonymous to udana.219

9) Shukra dosha:

Alpa prana is a symptom in beejopaghataja klaibya.220

10) Sthaulya:

Alpa prana is considered as roopa of sthaulya.221

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09) Prana Kshaya/Vruddhi

The extensive Ayurvedic literature has got mention of many entities like food items, medicines, herbs, hetu or awastha those can boost or diminish prana subtle/ prana vayu. They can be summarized in following manner.

A) Prana kshaya karak:

The kshayaja kind of rajayakshma is leads to prana kshaya. Its hetu include irshya, utkantha, bhaya, tras, krodha, shoka, anashana, Shukrakshaya. Thus manas bhava are important causative fectors of prana kshaya.222

The wind coming from west is having effect of diminishing prana element, instantaneously.223

According to Bhavamishra, pooti mamsa, vruddha stree, bala arka, tarun dadhi, prabhate maithuna, prabhate nidra immediately lead to pranakshaya224

B) Prana Vruddhi karak:

According to Bhavamishara, Sadya mamsa, vala stree, nava anna, ksheer bhojana, ushnodaka snana, ghruta immediately lead to pranakshaya.225

Appropriately administered sneha if gets digested properly, it enhances prana principle226

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After cutting of placenta, the neonate is made to listen a clapping sound made by stones. Neonate is also recommended to sprinkling or washing his/her face by cold / hot water. This leads to his/her kashtamukti. This leads to replenishment of prana in a neonate.227

After delivery of foetus, sutika is asked to tell her that she has delivered a baby. Listening to these words, sutika becomes harshita & there is prana sanchar in her mind & body.228

Lauhadi rasayana mentioned in third paada of rasayana chapter of charaka samhita is said to be prana vardhaka.

Mandur vatakam from pandu rogadhikara is having effect of enhancement of prana principle.229

The therapy of snehana itself replineshes prana principle in a individual, quotes charaka in vatavyadhi chikitsa chapter.230

In opinion of Sushrutacharya, purusha are sneha sadhya i.e. easily treated by sneha kalpana (fatty preparations). This vitality element of prana is snehabhooyishtha i.e. made up of sneha.231

According to Sushruta, dadhi (curd) is prana kara. i.e. enhances prana element.232

Mamsarasa is prana janana. i.e. enhances prana element.233

There is mention of a preparation made up of beejak etc. recommended for those who wishes replineshment of his prana & eye health.234 A preparation made up of gooduchi, triphala,..( Su.chi.38/50 Chi) etc is

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03 Review of literature said to be pranavardhana. Dalhana clarifies that it enhances agni, soma etc twelve kind of prana.235 Sevana of ushna ambu in jwara is said to be pranavalambana.236 In atisara chikitsa pranada i.e. haritaki is used in sama & doshabahula awastha. It empowers prana of patient.237 Paya i.e. milk empowers prana.238

Pranakamiya rasayana

Second paad of rasayana chikitsa chapter of charaka Samhita is entitled as ‗prana kamiya’ i.e. for desirous of prana element.

The chapter is having mention of herbs Aamlaki, Vidari, Jivanti, Bala, Shatavari, Shalishashti, Pippali, Palash, Vidang, Nagbala, Bhallataka, Agaru, chandan.

Treatment for prana:

Upward moving therapies for udana, downward moving therapies for Apana are indicated. Samana shall be brought to stability. All of these three modalities are indicated for vyana morbidity. Prana is more important that other four and it should be protected with priority. Its state of equilibrium helps in sustenance of life, says Charaka.239 Chikitsa sootra for prana is rakshana. Chakrapani clarifies rakshana as yapana.240 Term ‗Yapan’ means maintaince, support. (Monnier Williams: maintaince, support 849)

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10) Review of equivalent (with prana) concepts from other disciplines:

Vitality is the relevant term for Ayurvedic conceptualization of subtle prana. In an etymological view point it is simply idea or principle of life. Vigor or liveliness, excitement & energy are synonymous to same. Thus this very basic concept of vitality can be traced back in many of civilizations/cultures/medicines. in China as Chi the source of life, creativity, right action, and harmony. In Japan, the concept of Ki similarly entails energy and power on which one can draw and relates to physical, mental, and spiritual health. Balinese healers attempt to mobilize bayu, a vital spiritual or life force that varies among individuals, and represents what is needed to live, grow, and resist illness.

They can be listed as241:

Term Source Ankh Ancient Egypt Animal Magnetism Mesmer Arunquiltha Australian Aborigine Bioenergy United States, United Kingdom Biomagnetism United States, United Kingdom Gana South America Ki Japan Life Force General usage (e.g. "Ki" means "Life Force") Mana Polynesia Manitou Algonquin M'gbe Hiru Pygmy Mulungo Ghana Mumia Paracelsus

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Ntoro Ashanti Ntu Bantu Oki Huron Orenda Iriquois Pneuma Ancient Greece Prana India Qi (chi) China Subtle Energy United States, United Kingdom Sila Inuit Tane Hawaii Ton Dakota Wakan Lakota

Few important concepts from other disciplines sharing equivalence with that of prana are reviewed below.

Qi (Chi) & prana:

Pneuma & prana:

Yoga / pranic healing & prana:

Subjective vitality & prana:

Qi (Chi) & prana:

The biological element which makes ‗alive‘ & continues life is called Qi ("chee"). The concept of Qi is a pivotal concept in TCM (Traditional Chinese medicine) . Life is defined by Qi although it is not possible to grasp, measure, see or isolate. An imperceptible vigor known only by its effects, Qi is known indirectly by what it cultivates, generates & protects. Matter is nothing but Qi taking shape. forming Mountains,

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03 Review of literature growing forests, streaming rivers and proliferating creatures are all manifestations of Qi. In physiological viewpoint, all functions in the body and mind are manifestations of Qi. sensing, cogitating, feeling, digesting, stirring and propagating. Qi is considered as the the basic mystery and miracle. Belief in a restorative life energy that per-vades living things dates back to antiquity. Hindu prana, Chinese Qi (chi), and Japanese ki are a few examples of some sort of poorly understood vital energy that flows throughout the body and is intimately linked with physi-cal, mental, and spiritual health242.

Pneuma & prana: Athenaeus of attaleia pioneered the pneumatic school, in ancient greece. literally pneuma, means ―vital air‖ or ―breath.‖ Pneumatists although echoed stoic philosophy, but with their emphasis on primordial matter, the pneuma, the source of energy & life. Aristotle was the first to explain the ways in which the pneuma is introduced in body & sanguineous system erasistratus and his successors had made the pneuma act a great part in health and disease. Felix boenheim reports that, ‗today the question whether the indian doctrine of prana is older than the greek idea of pneuma is unanswerable. but...with the teachings of plato. pneuma corresponds exactly to prana.‘243 Apart from this history of circulation some of Galen‘s concepts show similarity with Ayurvedic concepts. As quoted by Patwardhan Kishor, ‗Galen believed that the blood was continuously being produced from the food that a person ingested. According to him, the vital spirit, ―Pneuma,‖ was derived through the act of respiration and was mixed with the blood in the left ventricle, and a portion of this passed through the septal pores into the venous blood of the right ventricle. In fact, Galen proposed that the function of arteries was to carry this Pneuma to the different parts.‘ He further quotes that Similarly, Pneuma and Prana too have a very close resemblance; however, the term ―Prana‖ has different contextual

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03 Review of literature meanings as well, rather than simply ―breath.‖244

Yoga / pranic healing & prana: Prana is the energy permeating the universe at all levels. It is physical, mental, intellectual, sexual, spiritual & cosmic energy. All physical energies such as heat, light, gravity, magnetism & electricity are also prana. It is the prime mover of all activities. Vigor, power, vitality, life & spirit are all forms of Prana.245 Pranic Healing is a claimed energy healing system pioneered by Choa Kok Sui (1952-2007) is practiced widely now a days. Although scholars of mainstream science believe it as supernatural/ pseudoscience, but there are some publications.(1340 publications on google scholar)

Subjective vitality & prana:

In the Oxford English Dictionary, vitality is defined as the state of being strong and active and the power giving continuance to life. vitality includes an aspect of autonomy or self-actualization allowing the expression of one's nature (from ethnolinguistics), and vitality has all of the dimensions of the life form which expresses it- in humans this includes physical, emotional, social and intellectual aspects (From other cultures). Ryan and Frederick (1997) have developed a scale of Subjective Vitality. In a series of studies, this scale was shown to be, in varied samples, associated with self-actualization, mental health, self-esteem, positive emotions, and greater self-motivation. Conversely, distress, negative emotions, and external locus of control were associated with less vitality.246 The scale is widely used by researchers worldwide as a tool in assessments of vitality.247

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C) Review of Mahasrotas & Hrudaya Sharir.

Mahasrotas: Mahasrotas is mentioned as pranavaha srotomoola & thus is needed to be reviewed. Commenting on same verse Gangadhara clarifies that, Mahasrotas is ‗mahachhidram mahasaranam’. This simply implies alimentary canal, the whole canal starting from much and end up to guda. It is inclusive of annavaha srotas & purishavaha srotas and is the seat of most important physiological entity of body i.e. jatharagni. Mahasrotas itself is a one of rogamarga. Koshtha or mahasrotas are synonymous, they are situated centrally in body it is from aamashya upto pakwashaya, and the same is known as aabhyantar roga marga,says Charaka.248

Gangadhara while commenting on cha.ni.3/7 clarifies that term mahasrotas is used synonymous with aamshaya as chhardi is a aamashaya pradoshaj vyadhi.249

Annavaha srotas: Vama parshwa (oesophagus) & aamashaya are considered as moola sthana of annavaha srotas says charaka.250 Sushrutacharya quotes that annavahi dhamani & aamashaya are moolasthana.251 Ashtang samgraha echoes charakacharya‘s quote.

Aamashaya sharir:

Charakacharya has quoted that portion of mahasrotas ranging from stana to nabhi shall be considered as amashaya.252

Commenting on the verse ah.ni.3/5-6 arundatta clarifies is as a portion (belonging to mahasrotas) between nabhi & stana.253 Commenting on

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03 Review of literature verse of similar context chakrapani datta on cha.ni.1/20 quotes same as portion between aamashaya & stana.254

Annavaha Dhamani:

Sushrutacharya considers amashaya and annavahini dhamani, as moolasthana of annavaha srotas. Alapati Vinod Kumar et.al consider all the arterial blood vessels can be related to the stomach is called annavaha dhamanis as the word anna indicates all the food material which is entering into the body and they will nourish each and every structure of the body.255

Purishavaha srotas: Pakwashaya & guda are considered as moolasthana of purishavaha srotas by both of charaka256 & Sushrutacharya.257 Uttarguda is enlisted after aamashya & pakwashaya among fifteen koshthanga.258

Pakwashaya sharir:

While discussing aashya sankhya (su. Sha.5/8) Dalhana comments that Pakwashaya is located downward to pittashaya where on one side there is unduka where separation of mala take place, and this unduka is apart from pakwashaya.259

Purishadhana is (Su.sha.3/6) enlisted among matruja bhava.260 Purishadhara kala is located inside pakwashaya &koshtha. In unduka there is separation between mala & sara bhaga.261 Vruddha vagbhata quotes that pakwashaya & sthoolantra are moolasthana of shakrutvahi srotas.262It is responsible for aayu, arogya,bala, varna, upachaya, ojus.263

Guda Sahrir:

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Guda is an important sadya pranahara marma. Vruddha Vagbhata mentions that it is situated next to sthoolantra & is for excretion of vata & purisham.264 The passage for excretion of shakrut is called as Guda, explains dalhana while commenting on su. Uttar 57/7265 Commenting on cha.su.9/3 gangadhar opine that sthula guda guda is trivali roopam impling rectum266

Grahani/ Pittadhara kala:

The term grahani itself signifies the organ meant for receiving undigested food & processing same with agni, says charaka.267 Pittadhara kala resides there in between aamashaya & pakwashaya. It is a lining to cover adhishthana of agni says sushruta. Pachana & shoshana takes place at grahani itself adds vruddha vagbhata.268

Importance of mahasrotas:

Mahasrotas is an important site for two of highly praiseworthy physiological entities viz dosha and agni.

Ayurveda considers the entity for digestion and metabolism in our body as Agni. Term agni is relevant for all physiological entities responsible for the term digestion of food and all metabolic processes. Dehagni is the cause of life, complexion, strength, health, nourishment, lusture, oja, teja (energy) and prana (life energy) as reviewed previously. (Cha. Chi. 15/3.) Charakacharya says that after stoppage of the function of Agni, the individual dies, and when the Agni of an individual is sama, then that person would be absolutely healthy and would lead a long, happy, healthy life. But, if the Agni of a person is vitiated, the whole metabolism in his body would be disturbed, resulting in ill health and disease. Hence agni is moola i.e. root of all269

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Dosha sthana: Dosha the Ayurvedic bioenergetic principles are again linked with mahasrotas very closely. Vata with pakwashaya, pitta with grahani & kapha with aamashaya.270 There is a unique classification of diseases as aamashaya originated & pakwashaya originated, in accordance with charaka.271 Where amashaya samutha vikara are usually kaphapittaja & pakwashaya samutha are vataja, adds chakrapani.272 Pawar Pradeep Shivram, Panja asitkumar et.al have reported that, ‗In disease of any srotas it is impossible to complete vamanadi panchakaramarupi shodhan chikitsa as well as dipan pachanadi saptavidha shaman chikitsa (ashtang su. 14/5,6)without support of mahasrotas. In this regard, mahasrotas is justified as unique or super controller of all srotas.‘273 Thus mahasrotas is highly praiseworthy being • place of jatharagni, • Place for process of awasthapaka • Place for udirana of dosha • As abhyantar roga marga • Route for vamana, virechana & basti.

Hence role of Mahasrotas in physiology of pranavaha srotas is needed to be explored.

Gut- Gut microbiota & relations with vital organs like brain, heart:

It‘s not alone Ayurveda to interlink gut with vital organs/systems. The interesting relationships of gut with brain is seen discussed by many other scientific streams across apart from oriental one. As famously remarked by Hippocrates, father of western medicine, ―all the diseases begin in the gut & death sits in the bowel‖. And thus generating the hypothesis that gastrointestinal canal is responsible for many disorders

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03 Review of literature including diseases of vital organs i.e. including cardiac & neural complications. Avicenna (a great Persian physician of 1000 years ago times) in his medical encyclopedia, ‗Canon of Medicine‘, reports that the stomach interacts with other organs, head in particular. Particularly flatulence affects other organs & especially neurological disorders.274 Gut is the only organ that contains an intrinsic nervous system that is able to mediate reflexes in complete absence of input from brain / spinal cord.275 Apart from secreted juices & their role in digestion as reported in conventional physiology of gastrointestinal system, role of ‗gut microbiota‘ has become a new key word in contemporary scientific community.

Since last decade ecological diversity of microbes living symbiotically within us is largely appreciated. Gut serves as an important harbor for large portion of them. In fact human gut marina has more than 100 trillion microbial cells. Thus making us as walking communities comprised of a Homo sapiens host, & trillions of symbiotic commensal microorganisms within the gut & on surface of our bodies.

The gut microbial ecosystem is even considered as largest endocrine organ in the body, proficient of producing a variety of biological compounds that, like hormones, those can be carried in the circulation and distributed to distant sites thereby influencing different biological processes.276

As Gut microbiota is reported to serve as a filter for our largest environmental exposure including what we eat, it is needed to be essentially considered under the comprehensive conceptualization of agni.

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Hrudaya Sharir:

Etymologically word Hrudaya is composed of three words i.e. hr-da-ya means the organ performs the duties of Aharana (Receives), Dana (gives), and Ayana (Movement). Thus hrudaya is a organ which receives, gives away & provides as a path for movement itself. Scientists like VV Subramaniyam Shastri report inclusion of thoracic heart, lungs, central nervous system & a cell by term hrudaya.277 However present context is restricted & comparative review of urastha hrudaya & shirastha hrudaya is already taken in consideration in previous subchapter & Thoracic heart is concluded to be relevant in said context.

Synonyms:

"Mahat" (Because of it‘s over all biological importance) and "Artha" (It is the organ par excellence so called as Artha) are synonyms of Hrudaya278

Chakrapani comments that hrudaya is mahamoola, as it has roots of great vessels. These vessels are dependent on heart.279

The anatomical considerations of hrudaya:

Hrudaya is taken into account as koshthanga while listing fifteen koshthanga as in cha.sha. 7/ 10. Hrudaya also serves seat for six Angas, intellect, indriya i.e. five types of sensory perceptions, aatma i.e. soul and mind.280 Hrudaya is located in between the two breasts nearby the opening of Amasaya and It is site for Satva, Raja, Tama and injury to it causes death immediately.281 Vagbhatacharya echoing Sushruta quote that, Hrudaya is the opening of Amasaya, it is place for satwa (mind) and through the same opening the liquid and solid food passes into Amasaya.282

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Pranavaha dhamani are attached to it. Pliha and Phuphphusa are found below and to the left side of Hrudaya; whereas Yakrit and Kloma on the right side of Hrudaya. Hrudaya resembles with lotus bud (in colour, shape & size. Its tip is hanging downwards says Sushruta.283 Haranchandra in his commentary on Sushruta Samhita has reported heart to be a four chambered organ.284 Hrudaya is stated to be 2 Anguli as per anguli pramana.285

Embryological considerations: Sushruta quotes that Hrudaya is formed by quality essence of rakta & kapha.286 Hrudaya is considered matruja avayava in embryological context by all acharya.287,288 In opinion of Charakacharya, Hrudaya is produced in third month of embryonic life also all Indriyas, all bodily organs are developed in the third month.289 Susruta opine the origin of Hrudaya is in the fourth month of embryonic life.290 According to Kritavirya, Hrudaya is the organ that is produced first in embryonic life as its site for the intellect and mind.291. Kankayana from balhik country also accepts the origin of Hrudaya to be the first during embryonic life.292

Hrudaya & Dosha, Dhatu, mala:

Hrudaya is produced from the essence of Rakta and Kapha (Su.Sha. 4/30). Hrudaya is a sira marma.293 Hrudaya is moolasthana of rasavaha & pranavaha srotas. Ojovaha sira commense from hrudaya only.294 Sadhaka pitta resides in hrudaya & serves as tool for buddhi, medha, dhee, abhiman opines vagbhata.295 Thus Hrudaya is related with prana, vyana vayu, sadhaka pitta, avalambaka kapha, rasa, rakta, ojus & mana.

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Ayurvedic considerations of Hrudaya & Circulation:

The term Rasa is derived from "Gatyarthak Rasadhatu" with its meaning that it moves continuously day and night.296 Sushrutacharya quotes, ‗Food that is composed of panchamahabhoota, of four kinds (drinkable, lickable, chewable & eatable), Having six rasa, having two or eight veerya, is digested & its quality derivative which is tejas & minute is called as rasa. Hrudaya is place of rasa & is transported by twenty four dhamani & results in tarpana, vardhana, dharana & yapana of sharir.297 Bhela states that the nutrient fluid comes into circulation from the heart spreads all over the body through Siras.298 Chakrapani‘s clarification (while commenting on role of vyana vayu in circulation of rasa dhatu at cha.chi.15/36 that ‗Raktadi’ are situated in hrudaya, is an important. It clearly indicates that rasa and rakta move from hrudaya to body parts.299 Charaka opines that Hrudaya is the an important site as it is residence of Satva, Intellect, Indriyas, Ojas, soul, and is pathway for movement of rasa dhatu, & vatadi dosha (vata,pitta, kapha) at Ca. Ci.24/35.300 In this verse some scholars believe in paathbheda meaning that it is pathway for rasa & other dhatu.301 Chakrapani in his commentary explains that hrudaya is pathway for all of tridosha as well as dhatu like rakta.302 Cakrapani states that here the term Rasa includes all circulating liquids along with Rakta.

This circulation /transport of rasa-rakta in body is said to take place as in three directions similar to those of shabda, archi & jala.303 Dalhana explains that examples of shabda, archi, & jala are for transverse, upward & downward directions respectively.304 Charaka himself has implicated that Tridosha and Mana has no specific Srotasa although these entities circulates through all channels of body. (in C.Vi.5/7). Sharngadhara has described that ―Samana Vayu‖ helps for

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03 Review of literature transportation of Rasa toward the heart.305 Patwardhan kishor has interpreted the circulating oxygenated blood as a mixture of ―Rasa‖ (often wrongly translated as ―Chyle‖), the nutrient fluid that nourishes rest of the tissues & ―Rakta,‖ the red fraction that is very essential for life & ―Ojas,‖ a white fraction, the functions of which are closely associated with immunity; and ―Prana,‖ a fraction that is derived through the act of respiration.306

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C) Review on CHD

a) Review of Modern Aspects of CHD b) Review for Ayurvedic interpretations of CHD

Review of Modern Aspects of CHD

Statastics:

CHDs stands as a number one cause of death globally: more people die annually from CHDs than from any other cause. WHO predicts 11.1 million deaths globally and 71% deaths in developing countries due to Coronary Artery Disease (CAD) by 2020 A.D. Out of the 16 million deaths under the age of 70 due to noncommunicable diseases, 82% are in low and middle income countries and 37% are caused by CHDs.307 CHD death rates (age) standardized in age group of 30-69 years old differ like 180 per 100,000 in UK, 280 per 100,000 in Republic of China and 405 per 100,000 in India.308 South Asians can be said to be at maximium risk as the median age for the first presentation of MI in them is 53 years whereas same in Western Europe, China and Hong Kong is 63 years.309 Studies carried out in India and other places suggest that Asians in general and Indians in particular are at increased risk of Myocardial Infarction at a younger age (<40years), irrespective of whether they have migrated to other countries or are resident Asians.275

Behavourial Risk factors:

The important Behavourial risk factors of heart disease and stroke include unhealthy diet, lack of physical activity, use of tobacco and intake of alcohol. These behavioural risk factors may manifest as

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03 Review of literature raised blood pressure, raised blood glucose levels, raised blood lipid levels, and overweight and obesity. These ―intermediary risks factors‖ can be measured in primary care facilities and indicate an increased risk of developing a heart attack, stroke, heart failure or other complications.

Termination of tobacco use, reduction of salt in the diet, consuming fruits and vegetables, regular physical activity and avoiding harmful use of alcohol have been shown to decrease the risk of cardiovascular disease. In addition, drug treatment of diabetes/ hypertension and high blood lipids is said to be necessary to minimize cardiovascular risk and prevent heart attacks and strokes. There are also a number of underlying determinants of CHDs or "the causes of the causes". These are a reflection of the major forces driving social, economic and cultural change – globalization, urbanization and population ageing. Other determinants of CHDs include poverty, stress and hereditary factors.Numerous primary and secondary prevention trials have shown that aggressive management of modifiable risk factors reduces death rates, myocardial infarction (MI), stroke, and other cardiovascular events, including the need for revascularization.

Apart from traditional risk factors, hyperhomocysteinemia is seen linked to CHD, cerebrovascular and peripheral vascular disease. Hyperhomocysteinemia denotes an increased concentration of an amino acid homocysteine which leads to atherogenesis by causing endothelial damage. Exposure of endothelial cells to homocysteine results in the formation of S-nitrosohomocysteine, a compound with antiplatelet and vasodilator properties. Also importance of hyperfibrinogenemia too is reported as risk factor for atherosclerosis.

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Symptoms:

Often, there are no symptoms of this underlying disease. Angina & stroke may be the first warning of underlying disease. ‗Angina‘ an acute pain of cardiac origin related to inadequate blood supply manifests as pain over left of chest or in retrosternol region. It can radiate to the neck, shoulders and to the tip of the fingers. It is a squeezing, stretching, constricting, pressing or crushing and is aggravated by exercise, heavy meals and is relieved by rest.

However in myocardial infarction (MI) the pain is similar to Anginal pain but signifies the blockage of the coronory vessels supplying to certain portion of the heart muscle. Infarction ca be result of sudden occlusion of vessel or may be secondary to ischemia. In addition the person may experience difficulty in breathing or shortness of breath; feeling sick or vomiting; feeling light-headed or faint; breaking into a cold sweat; and becoming pale. Women are more likely to have shortness of breath, nausea, vomiting, and back or jaw pain.

Sometimes manifestations include cyanosis, syncope, breathlessness thirst, confusion restlessness, Nausea, Vomiting, Frothy or blood mixed sputum, sweating and coldness of limbs.

Pathogenesis:

The Greek words, ‗sclerosis‘ literary means hardening whereas ‗athere‘ stands for gruel i.e. amassing of lipid. The phenomenon of atherosclerosis is characterized by accumulation of cholesterol, infiltration of macrophages, proliferation of smooth muscle cells (SMC), accumulation of connective tissue components and formation of thrombus. Although many systemic factors predispose to progression of

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CHD, the disease preferentially affects certain regions of the circulatory system. The growth of the lesion is abluminal in early stages of the disease, and the progress may vary from total cessation in some cases to very rapid with intervening periods of relative quiescence.310 Coronary lesions lead to myocardial ischemia or infarction. However, small lesions in the coronary circuit may lead to death when they occur along with arterial vasospasm.

Inflammation plays crucial role in CHD. The momentous organizing theme, that emerged first from laboratory studies and has now extended its currency in the clinics, accords inflammation a major role in all stages of atherogenesis.311 Also immunological factors are too seen important in said pathogenesis. The most significant data in support of a association between immunity and atherosclerosis comes from epidemiological studies of patients having autoimmune disorders. Patients with rheumatoid arthritis have a 2- to 5-fold increase in cardiovascular morbidity and mortality.312 Also patients with systemic lupus erythematosus show even higher increase in cardiovascular disease.313 Altered lipid metabolism is the most essential part in pathogenesis. Triglycerides, cholesterol and lipoproteins are implicated in the pathogenesis of coronary artery disease, especially atherosclerosis.314 Reduced concentrations of high density lipoprotein (HDL) and increased triglycerides have been shown to be responsible for the genesis of atherosclerotic lesions.315 Triglyceride concentrations greater than 2.25 mmol/L and LDL:HDL ratios greater than 5 were seen to be associated with a fivefold rise in the risk for cardiovascular events, especially in population with a metabolic syndrome, insulin resistance syndrome (characterized by a cluster of abnormalities such as hyperinsulinemia, insulin resistance and android fat distribution).316 In addition, the nonlipid mechanisms recognized to HDL are (a) inhibition of monocyte adhesion and migration into the arterial intima; (b)

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03 Review of literature stimulation of cell repair and proliferation; (c) preservation of endothelium-dependant vascular activity; (d) inhibition of growth factor- induced VSMC proliferation; and (e) prevention of thrombosis.317 Vascular endothelium in fact plays important role. Endothelium is a multifunctional endocrine organ located strategically between the blood and the vessel wall. It has a crucial role in determining vascular function and is intimately involved in atherosclerosis. It handles important regulatory functions that include regulation of vascular tone, formation of NO, prostacyclins and ETs, maintenance of the composition of subendothelial matrix, proliferation of SMC, coagulation, fibrinolysis, permeability of lipoproteins and plasma proteins, and adhesion and migration of blood cells. Most damaging elements for endothelium are the ROS produced by various risk factors of atherosclerosis such as cigarette smoking, stressful conditions, anaerobic metabolism and radiation. Initiation of oxidative stress through generation of ROS has been linked to diabetes mellitus and chronic uremia because these conditions are characterized by accumulation of ‗advanced glycation‘ end products.318 Damaged or excessively activated endothelial cells secrete vasoconstrictor factors such as ET-1, as well as factors affecting the differentiation and growth of VSMC. These exert a chemotactic action on leukocytes and platelets, and induce the expression of specific surface adhesion molecules (selectins, integrins and the supergene family of immunoglobulins) that interact with ligands on the surface of leukocytes and platelets. Cellular adhesion molecules such as intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1) and P selectin overexpressed on the surface of macrophages and endothelial cells are potential markers for atherosclerosis. These molecules mediate the adhesion of monocytes to the endothelial surface, followed by migration into the intima. ET-1 exerts a wide range of actions including vasoconstriction and mitogenic

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03 Review of literature activity on SMC, and results in the formation and release of free radicals and inflammatory cytokines into the circulation.319

Activated neutrophils contribute to endothelial damage and injury by producing ROS. Pronounced antithrombotic activities and reduced expression of plasminogen-activating factors by the damaged endothelial cells perpetrate the inflammatory process.320

There is a praiseworthy role of NO in the same. NO is a diatomic molecule that has cytoprotective and cytotoxic properties depending on its concentration. The homeostatic mechanisms of NO include vasodilation, inhibition of platelet adhesion and aggregation, reduction in leukocyte adherence, inhibition of SMC proliferation and inhibition of LDL uptake.321 Impairment of endothelium-dependant vasodilation in hypercholesterolemia is largely caused by reduced bioavailability of NO. This molecule is synthesized by a family of enzymes called the NO synthases from the amino acid L-arginine through the L-arginine-NO pathway.322 NO-related mechanisms contributing to progression of the atherosclerotic disease process include impairment of membrane receptors in the arterial wall that interact with agonist physiological stimuli capable of generating NO, reduced concentrations or impaired utilization of L-arginine, reduction in the concentration or activity of inducible and endothelial NO synthases, and impaired release of NO from damaged atherosclerotic endothelium.

Angiotensis, Chymase & oxidative stress & Reactive Oxygen Species:

Angiotensin II is the main mediator of the renin-angiotensin-aldosterone system, which maintains the physiological salt and water balance, blood pressure and vascular tone in the body. It is believed to be involved in atherosclerosis, endothelial dysfunction and ROS production. ROS are generated by a variety of extracellular and intra-cellular mechanisms

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03 Review of literature and are responsible for the oxidation of LDL. The extracellular production of ROS is mainly through the action of angiotensin II on the macrophages and endothelial cells; ROS production is also increased after the stimulation of endothelial cells by TNF-α and other cytokines. Intracellular ROS production in the VSMC is mainly through the membrane-bound NAD(P)H oxidases, xanthine oxidase and uncoupled NO synthase, which account for more than 90% of ROS production.323 Angiotensin II is a powerful inducer of NAD(P)H oxidase and can stimulate the production of ROS eightfold in the VSMC. ROS produced intracellularly in response to hormonal stimuli have been found to serve as second messengers.324 The formation of ROS in hypercholesterolemia is a result of an imbalance between their production and detoxification by antioxidant defence systems.

Atheroma formation:

Altered permeability of the endothelium to the lipoproteins that transport lipids such as cholesterol and triglycerides leads to their binding to the extracellular matrix constituents called proteoglycans Lipoprotein modification. Lipoproteins are modified by at least five different methods in the arterial wall; however, the oxidation carried out by the ROS and nonoxidative glycation in diabetes mellitus (mostly NIDDM) and chronic uremia is most significant. The oxidatively modified lipoproteins (oxLDL) are more atherogenic than the native LDL and lead to recruitment of the macrophages to the site of the lesion. The immune system identifies these modified lipoproteins as exogenous in nature, and the leukocytes infiltrate to clear these oxLDL from the intima of the artery. Thus, atherosclerosis is viewed as an autoimmune disease. Nonenzymatic glycation is seen mostly in diabetes mellitus (NIDDM), and the resultant AGEP have a multidirectional role in atherosclerosis. The AGEP not only interact with LDL, HDL and VLDL but also accelerate

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03 Review of literature their oxidative modification and uptake by the macrophages to form foam cells. In addition, AGEP block the formation of NO.325

Role of inflammatory cells and adhesion molecules:

Oxidatively modified lipoproteins promote the infiltration of T- lymphocytes, inflammatory mediators, hemoadhesive molecules and immunoregulatory molecules, and thus provide support to the hypothesis that atherosclerosis is an autoimmune disease.326 On the other hand, because endothelium is considered to be the stimulus for the migration of leukocytes, atherosclerosis is classified as an inflammatory disease.

Foam cell formation

Once resident in the intima, the monocytes differentiate into macrophages and exhibit enhanced expression of scavenger receptors, which bind lipoproteins for endocytosis. In an effort to clear the lipids, these macrophages first attach the lipoproteins to the scavenger receptors, and they result in the formation foam cells. Lack of the LDL receptors responsible for endocytosis is seen in patients with familial hypercholesterolemia, where they have an abundance of arterial lesions and multiple xanthomata containing foam cell-rich lesions. MSR were discovered in studies of patients with familial hypercholesterolemia.

VSMC proliferation and modulation

Macrophages engulfing the modified lipoproteins produce cytokines and growth factors, which in turn cause further recruitment of the macrophages and VSMC to the site of the lesion. IL-1 and TNF-α stimulate the local production of PDGF and FGF, which have a pivotal role in plaque formation and complication. PDGF is secreted by the

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03 Review of literature activated endothelial cells and causes migration of the SMC from the media to the intima.

A mitogenic factor (VEGF) that induces the development and formation of new blood vessels was isolated in 1989. It was found to influence tumour growth, wound healing, diabetic retinopathy and collateral formation in ischemic tissues.327

Infectious component in pathology:

Both viral and bacterial infectious agents have been implicated in the evolution of atherosclerosis; the common offending agents are the Chlamydia sp, Helicobacter pylori and cytomegalovirus.328 Seroepidemological studies have shown the presence of Chlamydia pneumoniae (the causative agent of persistent respiratory infections) in the atherosclerotic lesion.329

Thus Pathogenesis of atherosclerosis is needed to be viewed as a complex of multifactorial processes, involving interplay of genetic, metabolic, environmental, behavourial, immunological, psychological, degenerative & inflammatory factors.

An article in NJEM reports need of revisiting strategies for CHD. ‗…….A decade ago managements of hypercholesteromia & hypertension was expected to eliminate CAD by 20th century. Lately however that optimistic prediction needed revision. And thus forced to reconsider CHD and to reconsider new strategies, for prediction, prevention and treatment, reports Hansson Goran.330 A substantial burden of atherosclerosis can exist without producing stenosis.331 Traditional angiography provides only estimates of the severity of most lesions; ischemia may result from dynamic obstruction superimposed on fixed stenoses, and lesions can progress surprisingly rapidly, heralding a poor prognosis.332

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Concept of hrudroga:

Ayurveda is based on a tripod of Hetu- Linga- Aushadha. Being a causative factor, ‗hetu’ again is recognized as first in nidana panchaka. Linga /symptoms is a manifestation of underlining pathology & thus again considered in nidana panchaka. Enriched symptomatology is an important contributor to make Ayurveda indeed a treasure box. Aushadha is nothing but chikitsa. Thus newer diseases like CHD can be understood with help of nidana panchaka particularly by interpreting hetu (etiological factors) & lakshana.

So far as classical hrudroga is considered it is enlisted among rasapradoshaja vikara in Sushruta Samhita.333

Tri marma, asthi, sandhi, snayu, kandara sanyoga areas constitute the madhyama marga. Hrudroga is itemized under madhyama roga marga roga.334

Ayurvedic concept of hrudroga:

Excess of exercise, intake of excess teekshna guna, atiyoga of basti/ virechana/ vamana, chinta, bhaya, induction of improper medical treatments, aamdosha, vegavrodha, atiyoga of karshana, abhighata are considered as hetu of hrudroga according to Charaka in chikitsasthana.335 However in sootrasthana he has mentioned separate hetu according to doshaj types. Shoka, upavasa, vyayama, rooksha, shushka, alpabhojana are hetu of vataja hrudroga.336 Ushna, amla, lavana, kshar, katu, ajeernabhojana, madya, krodha & aatap are hetu for pittaja type.337 Kaphaja hrudroga is caused by excess guru, snigdha bhojana, achintana, lack of exercise & excess sleep.338 Excess intake of tila, ksheera, guda leads to kledana in rasa dhatu and results in krumija hrudroga says Charaka.339

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Vaivarnya, moorcha, jwara, kasa, hikka, shwasa, aasyavairasya, trushna, pramoha, chardi, utklesha of kapha, aruchi are symptoms of kaphaja hrudroga.340 Vataj hrudroga manifests as hollowness in heart, feeling of pain, congestive pain, cutting pain & dryness in hrudaya.341 Pittaj hrudroga manifests as tama pravesha, udayana, daha, moha, taap, jwara & yellowness, 342 whereas kaphaja hrudroga manifests as heaviness & congestion in heart, feeling as if heart is covered by moist cloth, praseka,jwara, kasa & tandra.343 Sannipataka hrudroga manifests all of the lakshana & if manifested as piercing pain & severe pain & etching at hrudaya it shall be considered as krumija hrudroga.344 Virudha ahara, excess ahar, ajeernashana & asatmya ashana are unique hetu (in addition) as mentioned by Sushruta.345

Altered Status of dosha-dhatu-mala in Hrudroga:

Inappropriate gati of Vayu is a major element in pathology of hrudroga in view point of Charaka.346 Causative factors of hrudroga are to be considered same as that of gulma.347 Again gulma is a disease where vayu is vitiated & has become vimargaga in kukshi, hrudaya, basti & guda marga.348

Hrudaya related symptoms in Vegavarodha:

Vegavrodha is a unique aetiological consideration in Ayurveda. Almost all impulses are related with prana & hrudaya. Hrudaya being site of prana, vyana, udana & even apana is seen invariably affected in majority of vegavrodha. They can be listed like:

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Symptom Vegavrodha of Classic Chapter Hrudi vyatha Shukra Charaka Su. 7 Hrudaya vibandha udgar Charaka Su. 7 Hrudi vyatha Pipasa Charaka Su. 7 Hrudroga Bashpa Charaka Su. 7 Hrudroga Shrama Shwas Charaka Su. 7 Hrud gada Adhovata Ashtang Hrudaya Su. 4 Hrudaya uparodha shakrut Ashtang Hrudaya Su. 4 Hrudaya vibandha udgar Ashtang Hrudaya Su. 4 Hrud gada Pipasa Ashtang Hrudaya Su. 4 Hrud aamay Kasa Ashtang Hrudaya Su. 4 Hrudroga Shrama Shwas Ashtang Hrudaya Su. 4 Hrudroga Bashpa Ashtang Hrudaya Su. 4 Hrudaya uparodha Mootra Ashtang Hrudaya Su. 4 Hrudvyatha Shukra Ashtang Hrudaya Su. 4 Hrudaya uparodha purisha Sushrut Uttar Uttar 55 Hrudi vyatha Pipasa Sushrut Uttar Uttar 55 Hrudroga Shrama Shwas Sushrut Uttar Uttar 55 SUMMURY: Adharaniya Vega Charaka Su. Sushrut Uttar As. Hrudaya Su. 4 7 55 Purisha --   Udgar  --  Pipasa    Shrama Shwas    Shukra  --  Bashpa  --  Adhovata -- --  Kasa -- -- 

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Mootra -- -- 

Hrudaya related symptoms in Panchakarma:

There are many hrudaya related symptoms seen in panchakarma complications.

A.H. chi. 1/6: Hrudroga is one of complications if vamana is given mistakenly to sama Jwara patient in case.

Hrudroga is vamana vyapad cha.si. 2/9

Teekshna virechana & Teekshna basti hetu of hrudroga in cha. 26

Cha. Si. 2/12: Virechana vyapad: dosha apravartamana

Su. Chi.37/88: Anuvasana vyapad: Hrudaya Peeda: atyasheete annabhibhavat apravrutta aushadha

Su. Chi. 33/8 :Vamana atiyoga: Hrudaya Peeda

Vamana vyapada: san. Su. 27/14: Hrudaya Peeda

Hrudaya graham: anuvasana basti vyapad:purishavruta: cha.si.4/36

Hrudaya graham: Vamana ayoga: su.chi.34/10

Hrudaya graham: virechana vyapad:ayoga su.chi. 34/10

Hrudaya upasarana : samshodhana vyapad: su. Chi. 34/19

Hrudaya rooja : niruha ayoga: cha. Si. 1/42

Hrudaya uparodha: vamana vyapad vamana to hrudrogi: cha. Si. 2/9

Hrudaya uparodha: Samshodhana vyapad: Ratha kshobha: cha. Si. 12/13

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Hrudroga is complication of Udavarta. Cha. Vi.26/8, ah.ni. 7/50

Hrudroga is complication of untreated aavrut vata cha.chi 28/236, va.ni.16/58

Kapha vruddha, vata ksheena, Pitta prakrutistha: Hrudroga is considered as a symptom. Cha. Su. 17/52

Hrudaya related symptoms (paratantra hrudroga) in other systemic illness:

Disease/ In vyadhi Applied Physiology Reference Symptom (dosha-dushya involvement) of vyadhi Hrudroga as kaphja gulma Viloma Vata, Rakta, Cha.Ni.3/11 Roopa Hrudroga as Krumirog Kleda, Su. Uttar. Roopa Santarpanotha 54/18 Hrudroga as Kaphaj krumi Kleda, kapha Su. Uttar. Roopa 54/14 Hrudroga as Purishajkrumi Kleda, Purisha Su. Uttar. Roopa 54/9/10 Hrudroga as Bijopghataj Shukra Cha.chi Roopa klaibya 30/161 Hrudroga as Vishaj jwara Visha, Rasa Va ni 2/41 Roopa Hrudroga as Apanasya Aavarana Vayu Cha. Chi Roopa samanen aavrut 28/205 Hrudroga as Udanasya pranen Aavarana Vayu Cha. Chi Roopa aavrut 28/207 Hrudroga as Vatasya kupitisya Kupita Vayu Cha. Chi

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Roopa 28/25 Hrudroga as Vikshaya Madya, Visha Cha. Chi Roopa 24/202 Hrudroga as Dooshi visha Visha Su. Ka. 2/53 Roopa

Hrudaya Vataj arochaka Aamashaya, Bodhak Su. Utta. 57/4 shoola as kapha Roopa Hrudaya Arsha Viloma vata & Ah.Ni. 14/26 shoola as agnivaishamya. Roopa Hrudaya Ajatodaka Udara Samana, Cha. Chi. shoola as prana,apana, agni 13/56 Roopa Hrudaya Baddha Gudodar Samana, Cha. Chi. shoola as prana,apana, agni 13/41 Roopa Hrudaya Udavarta Viloma vata Su. Uttar shoola as 55/39 Roopa Hrudaya Vataj kasa Viloma vata Su. Uttar shoola as 52/8 Roopa Hrudaya Vataj Gulma Viloma vata, rakta Su. Uttar shoola as 42/10 Roopa Hrudaya Aamaj Trushna Ambuvaha srotas Su. Uttar shoola as 48/14 Roopa

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Hrudaya Pittaj Prameha Kleda, pitta, meda Su. Ni. 6/13 shoola as Roopa Hrudaya Rasa Kshaya Raukshya Cha. Su. shoola as 17/64 Roopa

Hrudaya Ateesara Mahasrotas, Su. Uttar Toda as Pakwashaya 40/8 Purvaroopa Hrudaya Vataj Apasmara Hrudaya-mana-shira Su. Uttar Toda as 61/16 Purvaroopa Hrudaya Paana vibhrama Hrudaya-mana-shira Su. Uttar Toda as 47/21 Purvaroopa

Hrudaya Vataj Arochaka Aamashaya, Bodhak Su. Uttar Peeda as kapha 57/4 Roopa Hrudaya Vataj Grahani Mahasrotas, grahani Cha. Chi. Peeda as 15/62 Roopa Hrudaya Vataj Chhardi Aamashaya Cha. Chi. Peeda as 20/7 Roopa Hrudaya Ksheena Purisha Mahasrotas, Su. Su. 15/11 Peeda as Pakwashaya, Roopa Hrudaya Mootra sharkara Basti, mehana Su.Ni.3/15

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Peeda as Roopa Hrudaya Moorchha Hrudaya-mana-shira Su. Uttar Peeda as 46/5 Poorvarupa Hrudaya Kashaya rasa Raukshaya Su. Su. 42/9 Peeda as Roopa Hrudaya Sthawar dhatu Visha Su. Kalpa. Peeda as visha 2/10 Roopa Hrudaya Apatantraka Kupita vata Cha. Si. 9/12 Peeda as Roopa Hrudaya Raktapitta Rakta, pitta, Su. Uttar Peeda as vasculopathies 45/9 Upadrava Hrudaya Aavruta vatasya Vata aavruta Ah. San. Peeda as dhatu bhi sarvai 16/43 Roopa

Hrudaya Ksharkarma Aushnya, ahitkar Ah. Sang. Su. vedana as vibhrama dravya, 39/13 Roopa Hrudaya Aabhyantar gulma Viloma vata, rakta Va. Ni.11/58 vedana as Roopa Hrudaya Kamaj jwara Rasa, aamashaya, Su. Uttar vedana as mana 39/78 Roopa

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Hrudaya Ajatodaka udara Prana,apana,samana Ah. Ni. 12/11 vedana as vitiation Roopa

Hrudaya Arsha Viloma vata Ah. Ni.5/80 Rooja as Roopa Hrudaya Baddha gudodara Prana,apana,samana Ah. Ni. 12/30 Rooja as vitiation & viloma Roopa vata Hrudaya Vataj gulma Viloma vata & Cha. Chi. Rooja as rakushya. 5/10 Roopa Hrudaya Vataj jwar Vimargagamana of Su. Uttar Rooja as agni in rasa 39/30 Roopa Hrudaya Langhana Ksheena rasa dhatu Ah. Su. 14/30 Rooja as ateeyoga Roopa Hrudaya Amashaya gata Vata prakopa in Cha. Chi. Rooja as vata amashaya (place of 28/27 Roopa kapha) Hrudaya Visuchika Vata prakopa, Su. uttar 56/6 Rooja as mahasrotas Roopa Hrudaya Kshataj visarpa Abhighata , rakta Ah. Ni. 13/66 Rooja as dushti, rasa- twak Roopa dushti.

Hrudaya Kale aahar Amashaya ashuddhi Cha. Vi. 1/24

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Shuddhi as sevana Roopa Hrudaya Jeerna aahar Amashaya ashuddhi Cha.chi. Shuddhi as sevana 30/303 Roopa

Hrudaya Unmada Manas- hrudaya, Cha. Chi. 9/6 Shunyatwam ojus as Roopa Hrudaya Rasa kshya Ksheena rasa Su.Su. 15/9 Shunyatwam as Roopa

Hrudaya Shwas Pranavaha srotas Cha. Chi. Shosha as dushti 17/8 Roopa Hrudaya Hikka Pranavaha srotas Cha. Chi. Shosha as dushti 17/8 Roopa

Hrudaya apasmar Manas- Hrudaya Su. Uttar Kampa as 61/7 Poorvarupa Hrudaya Rasa ksheena Rasa ksheena Su. Su. 15/9 Kampa as Roopa Hrudaya Udar Udakodara Prana,apana,samana Su. Ni. 7/23 Kampa as vitiation, mala Roopa sanchiti Hrudaya Mahahikka Pranavaha srotas Su. Uttar

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Kampa as dushti 50/14 Roopa

Hrudaya Kapha ksheena Kapha ksheena Ah. Sang. Su. Dravata as 19/5 Roopa Hrudaya Pandu Rasa, pitta pradhana Ah.Ni. 13/4 Dravata as tridosha, hrudaya Roopa Hrudaya Rasa ksheena Rasa ksheena Ah. Sang. Su. Dravata as 19/6 Roopa

Hrudaya Rasasheshajeerna Rasa, agni mandya Su. Su. gaurava as 46/503 Roopa Hrudaya Shakhashrita Rakta, yakrut Va.chi. 16/47 gaurava as kamla Roopa Hrudaya Kaphaj kasa Pranavaha srotas, Va. Ni. 3/26 gaurava as viloma vata Roopa Hrudaya Kaphaj grahani Grahani, agni Su. Uttar gaurava as vitiation 40/176 Roopa

Hrudaya Unmada Doshaja Manas- hrudaya, Cha. Ni.7/6 graham as ojus Poorvarupa Hrudaya Apasmara Manas- Hrudaya Cha. Ni.8/6

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03 Review of literature graham as Poorvarupa Hrudaya Vataj jwara Vimargagamana of Cha. Ni. 1/21 graham as agni in rasa Roopa Hrudaya Vataj prameha Kleda, vayu,meda Su. Ni. 6/13 graham as Upadrava Hrudaya Vataj Madyatyaya Yakrut, Su.Uttar graham as hrudaya,manas 47/18 Roopa Hrudaya Sahaj arsha Viloma vata & Cha. Chi 14/8 graham as agnivaishamya. Roopa

Hrudaya Kaphaj arsha Viloma vata & Cha. Chi. Upalepa as agnivaishamya. 14/17 Roopa Hrudaya Kaphaj gulma Viloma vata & Sang.ni.11/39 Upalepa as rakushya. Roopa Hrudaya Kaphaj jwara Vimargagamana of Cha. Ni.1/27 Upalepa as agni in rasa Roopa Hrudaya Sahaj arsha Viloma vata & Cha. Chi. Upalepa as agnivaishamya. 14/8 Roopa

Thus it can be understood that being hrudaya is place of prana, vyana , udana & apana vayu, sadhaka pitta, kapha, ojus, manas & rasa dhatu. It

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03 Review of literature is an important pranayatana & is seen affected in secondary manner in many of systemic diseases involving these bhava.

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32 प्राणिती अनेन इतत

33 Monneire Williams, (1899 1st ed.). (Reprint 1995), A Sanskrit English Dictionary by Motilal Banarasidas Publishers Pvt. Limited, Delhi, Page – 24

34 Monneire Williams, (1899 1st ed.). (Reprint 1995), A Sanskrit English Dictionary by Motilal Banarasidas Publishers Pvt. Limited, Delhi, Page – 652

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37 Ch.Chi. 28/234

38 Ch.Su. 25/18

39 Ch. Su. 29/4

40 Ch. Vi. 6/19

41

Ch. Su.9/18

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43 Ch. Chi. 15/3

44 Jadavaji, T., Acharya (Ed.). (1997). Sushruta Samhita (6th ed.). Varanasi, India: Chaukhambha Orientalia, Nibandha Sangraha Commentary.Page-512, Verse-3

45 Ch. Su.1/109

46 Jadavaji, T., Acharya (Ed.). (1997). Sushruta Samhita (6th ed.). Varanasi, India: Chaukhambha Orientalia, Nibandha Sangraha Commentary.Page-22, Verse-9 Charaka Samhita with Chrakopskar commentry by Yogendranath Sen, JN Sen Prasannakumar Thakur street, kolkata.Verse: Ch. Su. 1/109 Page-41

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52 Su.su 21/5

53 …. Ch.Su.12/7

54 Paradakar, H., (Ed.). (2002). Ashtanghrudaya by Vagbhata (9th ed.). Varanasi, India: Chaukhambha Orientalia, As. Su. 20/2.

55 Athwale Anant Damodar (editor), Ashtanga Samgraha, (1980) Ayurvidya Mudranalaya, Pune. Indu on As. Su. 20/2 Page 146

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56 Ca. Sa. 1/29-30

57 Ca. Vi. 8/98

58 Su. Ni. 1/9

59 Jadavaji, T., Acharya (Ed.). (1997). Sushruta Samhita (6th ed.). Varanasi, India: Chaukhambha Orientalia, Nibandha Sangraha Commentary.Page-257, Verse-8 (Dalhana)

60 , ; Gayadasa on Su.Ni.1/8 61 Su.Ni.1/8

62 Ch. Chi. 28/6

63 Ah. Su.12/4

64 Paradakar, H., (Ed.). (2002). Ashtanghrudaya by Vagbhata (9th ed.). Varanasi, India: Chaukhambha Orientalia, Page-193,Verse- 4

65 Su. Ni. 1/13

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70. Va. Ni. 16/19

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72 Ch.Sh. 1/17

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74

Ch. Sha 3: 10

75 Ch.Vi.5/8

76 cÉ¢ümÉÉÍhÉÈ mÉëÉhÉuÉWûÉlÉÉÍqÉÌiÉ uÉÉiÉxÉÇ¥ÉmüuÉÉiÉuÉWûÉlÉÉqÉç LiÉŠ mÉëÉhÉÉZrÉÌuÉÍzɹxrÉ uÉÉrÉÉå ÌuÉÍzɹx§ÉÉåiÉ: xÉÉqÉÉlrÉålÉ iÉÑ uÉÉrÉÉåÈ LuÉ kÉqÉlrÉ CÌiÉ lÉ ÌuÉUÉåkÉÈ qÉÔsÉÍqÉÌiÉmÉëpÉÉuÉxjÉÉlÉqÉç Chakrapani on Ch.Vi.5/8

77 aÉÇaÉÉkÉU: qÉÔsÉiÉÉå urÉÉZrÉÉrÉiÉå iɧÉåirÉÉÌS iÉ§É mÉëÉhÉÉÌSuÉWåûwÉÑ x§ÉÉåiÉÈxÉÑ qÉkrÉå ™SrÉÇ uɤÉÈ, qÉWûÉx§ÉÉåiÉxÉ¶É qÉWûÉxÉUhÉçÇ qÉWûÉÎcNûÌSìèqÉirÉjÉïÈ Gangadhara on Ch.Vi.5/8

78 (Su. Sha.9/12) ‘ ’ .|

79 Jadavaji, T., Acharya (Ed.). (1997). Sushruta Samhita (6th ed.). Varanasi, India: Chaukhambha Orientalia, Nibandha Sangraha Commentary.Page-386, Verse-12 (Dalhana)

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135

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191 Ch. Chi. 8/27

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203 Su. Ut. 52/5

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Ch.Chi.28/207

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213 Ah. Ni.16/52

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215 ………………… Ah.Ni. 16/42

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269

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288

…………………………….. Ch. Sha. 3/6

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118

Methodology

Methodology should not be a fixed track to a fixed destination. But a conversation about everything that could be made of happen. (J C Jones)

04 Methodology

Methodology

CHD is a disease of hrudaya. Shwasa which is dushti lakshana of pranavaha srotas, is important symptom in CHD It is also statistically significant in Asian/Indian community. Thus was selected for observational study to understand relation of hrudaya, mahasrotas & prana. In this context prana is subtle prana as well as prana vayu.

Hypothesis: Hrudaya & mahasrotas are moolasthana of one & same srotas i.e. pranavaha srotas. Association of these two might be reflected in pranavahasroto dushti ex. CHD. Retrospective observational study of CHD subjects may be fruitful in same regards. And thus physiological interrelationship of hrudaya, mahasrotas & prana can be explored.

Study Design: It was a two phase work.

Conceptual study: Study of concept of prana in ayurveda was a fundamental kind of study done with literary method.

Observational study: To verify the perception of principles that was made in literary study, an observational study (with survey as a tool) was planned. Functional status of Mahasrotas and pranavaha & rasavaha srotas was evaluated, with a specially designed questionnaire.

Conceptual study:

One can observe changes in interpretation methods over the period of time as per need of same. Variety kind of Ayurvedic literature Tantra, Samhita, Tika, and Sangraha-grantha etc. are result of the same. However in spite of these external changes in structure of shastra one can trace a common methodology, that enabled those scholars of

119

04 Methodology respective times to interpret the classics into applications needed according to times. Unfortunately epistemology of Indian science was compromised in earlier times because of hostile environments during a series of invasions & unfavorable Colonial British rule and the impact of western medicine observes Patwardhan Bhushan. 1 The ignorance towards epistemology & methodology for appropriate interpretation of original verses has lead to various controversies and confusions as seen in today’s scientific literature of Ayurveda.

Now a day, the atmosphere of research is again giving life to every science. In such an encouraging environment, it was worth to go for studies of original concepts. As this was a work on epistemology its initial phase was an extensive literary study.

Materials:

i. All classics (brihat trai, laghu trai & allied) of Ayurveda with all available commentaries, related ayurvedic books, ayurveda journals & periodicals of ayurveda. ii. Veda, Upanishada, Yoga literature. iii. Texts of medical physiology & relevant parts of cardiology from books of pathology & medicine.

Methodology

References of prana from Veda, Upanishada (Shankar Bhashya), Purana, Bhagvad geeta, Bhagvatam, Darshana shastra, yoga grantha like hath yoga Pradipika, Patanjal Yoga darshana, many other, All classics (brihat trai, laghu trai & allied) of Ayurveda with all available commentaries, Dissertations, Periodicals & Peer reviewed Journals, Sharir kriya & other subject’s Curricular books were compiled.

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04 Methodology

Commentaries were referred. References were interpreted in their own contexts. Interpretation of ‘Prana’ in different contextual frameworks was done. Lastly Meta-analysis of these contexts was made & a holistic understanding of prana was put forth.

Study location: Bharati Vidyapeeth College of Ayurved, Pune-43.

Observational Study:

To support findings of literary study it was planned to opt for a, cross sectional observational study using survey as technique & questionnaire as a tool & structured interview as a method for the same.

Ethical Clearance: As per the ICMR guidelines for Ethical Research, the proposal of this study was presented before ‘Institutional Ethics Committee’ (IEC), BVDU, College of Ayurved, Pune. Meeting of Institutional Ethical committee held on 22/03/2013. Approval (BVDUCOA/ EC/186/ 13-14 dated 01/06/13) from Institutional Ethical committee was received and work was started after IEC approval.

Materials:

i. Specially designed questionnaire. ii. 150 pre-diagnosed patients of coronary heart disease those qualifying inclusion criteria & willing to participate the study.

Methodology:

Designing of the preliminary tool i.e. Questionnaire

It was decided to use a questionnaire as a tool for proposed observational study. Thus development of tool i.e. questionnaire was the initial work. Primarily the questionnaire was intended for examination of mahasrotas.

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04 Methodology

It was decided to derive questions from verses mentioned in Charaka Samhita for dushti hetu & dushti lakshana of annavaha & purishavaha srotas.

Agnidushti hetu & lakshana were decided to be derived from verses of Charaka Grahani chikitsa chapter.

Rasavaha & Pranavaha sroto dushti & lakshana questions too were decided to be framed from respective verses of Charaka Samhita.

‘Pranakshayakaraka’ is an adjective used for kshayaj yakshma in Charaka Samhita Yakshma chikitsa chapter. Questions for kshaya were developed from said verse.

Questionnaire designing process included decisions on type of Questionnaire, type of questions & also type of interview method. It was decided to frame a mixed kind of questionnaire to justify different contexts of variety of hetu & lakshana. As responses to questions were varying in their structure, some questions were decided to keep as closed ended, some to be open ended & some to be dichotomous one. Most of questions were designed as closed ended so that they would be easy to quantify the items & make tool more reliable. In some cases like questions based upon manas bhava rating scale questions was used. There was no colour coding or instructions for interviewee as the mode of Questionnaire administration was a Face-to-face questionnaire administration, where an interviewer presented the items orally.

Designing operational definitions for each of key words was done by thorough literary study. Commentaries were referred to aptly understand terms/ concepts like Chhardi 2 , Vishtambha 3 , avipaka 4 , jeerna ahar lakshana 5 , Atopa 6 , ashraddha 7 , aruchi 8 , asyavairasya 9 , vishamashana10, arochaka11, anannabhilasha12, adhyashana13 ahitasya bhojana14, vidharana15, krusha16,bhojana kala nishchiti17, durbalagni18

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04 Methodology ajeernadhyashana 19 , ahitashana 20 , pramitashana 21 , adhmana 22 & anaha.23 Then only design of questions was structured.

While interpreting ‘krushtwa’, BMI less than 18.5 was considered as it is already standardized.

Validating the questionnaire

The questionnaire to be developed was based on hetu & lakshana of srotamsi. It was essential to understand all those verse in a scientific manner. The first draft of questionnaire was developed after confirming necessity of each question & thorough understanding of verse for developing questions. Interpretations were made using available commentaries & studying allied literature. Drafts of the questions were prepared with appropriate framing of words to suit to exact meaning. It was sent to 10 peers for assessment. One peer suggested use of questions from already standardized questioners from field of psychology for assessment of manas bhava like irshya, shoka etc. The suggestion was implemented. According to said suggestion, questions from established valid questionnaires of anger24, anxiety25, envy/jealousy26, fear 27 & worry 28 were compiled & studied properly. Ayurvedic interpretations of terms like krodha, shoka, irshya, bhya, utkantha were studied using commentaries. Those questions having equivalence with ayurvedic meaning were added in questionnaire.

Some more minor suggestions & reframing of words suggested by peers was implemented. Thus the content validity of questionnaire was ascertained.

Piloting the questionnaire:

Until it was practically used in interviews and with patients, it was impossible to say whether it is going to achieve the desired results. Pilot study was carried out on 15(10%) patients. This helped in understanding

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04 Methodology that questions are understood by all classes of patients. Few corrections in framing of words were done in same regards.

Reliability of questionnaire:

The reliability of the questionnaire was examined using by applying Cronbach’s alpha which indicates good internal consistency of the items in the scale. In the pilot study value of Cronbach’s alpha i.e 0.76 was obtained for overall scales. This underlines reliability of questionnaire. There was no question about inter rater reliability as researcher himself has conducted all the interviews.

Source of Data:

150 pre diagnosed patients (coronary angiography done) of coronary heart disease were selected from Bharati Medical Foundation’s hospitals & other Pune based hospitals & Ayurvedic clinics. Subjects who fulfill inclusion criteria & were willing to be included in study were included. Written consent was obtained from patients before survey.

Inclusion criteria:

Patients pre diagnosed for CHD after coronary angiography.

Single / bi / tri vessel disease with one of blockage not less than 35%.

Both male & female will be included.

Age 30- 60 years of age, both male & female.

Patients of CHD those have undergone angioplasty within 03 months.

Exclusion criteria:

Patients of CHD with other major systemic disease.

Patients of CHD with DM.

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04 Methodology

Patients of CHD with all kinds of acute conditions.

Patients taking medication for gastrointestinal complaints. ex. laxatives, antacids, or ayurvedic preparations /therapies for same.

Sample size:

Sample size will be 143 determined by Sample size formula (as recommended by statistician) n= Z² x P(1-P)/d² where n=total no. Z=1.96 Standard normal value, P=prevalence of disease, d=0.05maximum error) It was rounded to 150.

Study location: Hospitals of BVMF (Bharati Vidyapeeth Medical Foundation) & other Pune based Ayurvedic & Allopathic Clinics.

Method of data collection:

Patients fulfilling above mentioned criteria were provided with consent form. After obtaining due consent from patients, they were interviewed with questionnaire. Nine patients denied giving structured interview due to inadequacy of time, unwillingness & some other reasons.

Consent form:

Consent form for said interview with questionnaire was prepared in English as well as in regional language i.e. Marathi.

Interview method: Structured Interview

It was a individual interview & not a group interview. The method of interview used in study was structured interview, as the questions asked were a set / standardized order and the interviewer was supposed to ask them in a prescribed interview schedule. However questionnaire contained few open-ended questions where interviewer (scholar) took liberty of asking sub-questions for a deeper understanding or

125

04 Methodology clarification on the items in questionnaire. Face to face method of interview promised the validity of answers.

Method of data processing:

Interviews were conducted in said manner. Four patients denied to give consent & interview. Master chart was prepared. It was interpreted under expertise of an experienced bio-statistician. Tests were applied & preparation of graphs was done.

The questions selected which were relevant to the research topic are divided into three parts according to the number of options for each questions as two options, three options and five options. The analysis was done using SPSS tool-Non Parametric Chi-Square Test. And the bar graph representing the choices by the participants for the selected questions was drawn using Excel Tool, under guidance of biostatistician.

Discussing Outcome

Appropriate statistical tests of association were applied to interpret observations. Outcomes of observational study & literary study were discussed in context with stated aim of study of, ‘physiological interrelationship of hrudaya, mahasrotas & prana’. Appropriate conclusions were drawn.

REFERENCES:

1 Patwardhan B. Traditions, rituals and science of Ayurveda. J Ayurveda Integr Med 2014;5:131-3.)

2 NûÌSï :

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04 Methodology

AÉsÉÑMÇü cÉÉ mÉÉPûpÉåS qÉÔsÉMüqÉÔMÇüSÉlÉÉqÉ I ÌlÉMÑücÉTüsÉÇ CWÒûTüsÉÇ TüsÉÉlÉÉqÉç I......

21 mÉëÍqÉiÉÉzÉlÉqÉ: ç AiÉÏiÉMüÉsÉpÉÉåeÉlÉÇ xiÉÉåMüpÉÉåeÉlÉÇ uÉÉ I cÉ¢ümÉÉhÉÏ cÉ.xÉÔ.25 AaêrÉxÉXçaÉëWû

22 आ鵍मान: उदरे वायोरतीव संचय: अननऱपुरणम च.सु. २६-१०२ 23 आनाह : उदरया鵍मानं वायुना परीपूरणम च.वव.२-७

24 : Miers, A.C., Rieffe, C., Meerum Terwogt, M., Cowan, R. & Linden, W. (2007). The relation between anger coping strategies, anger mood and somatic complaints in children and adolescents. J. of Abnormal Child Psychology, 35, 653-664.

25 Anxiety Robert L. Spitzer, MD; Kurt Kroenke, MD; Janet B. W. Williams, DSW; Bernd Lo¨we, MD, PhD, The GAD-7 A Brief Measure for Assessing Generalized Anxiety Disorder ARCH INTERN MED/VOL 166, MAY 22, 2006 American Medical Association

26 http://www.armonikizoi.com/2011/questionnaire-understanding-jealousy- and-envy & http://www.drjudithorloff.com/Free-Articles/quiz-envy.htm

27 Unit of developmental & Educational psychology, Institute of psychology, Leiden University

28 http://www.facingbereavement.co.uk/questionnaire-do-you-need- bereavement-counselling.html

129

Observations

One can state, without exaggeration, that the observation of and the search for similarities and differences are the basis of all human knowledge.

(Sir Alfred Nobel)

05 Observations

Observations

Occupation:

Amongst 150 participants 24 percent participants belonged to administrative class, 19% of them were professionals, 35% were from worker class and 22 % were from entrepreneur class.

Pulse:

Pulse varied from 69 per minute to 88 per minute.

Blood Pressure:

Systolic blood pressure varied from 76 mm of Hg upto 156 mm of hg whereas diastolic blood pressure varied from 66 mm of Hg upto 92 mm of hg.

Nadi:

Amongst 150 participants 48% were having vata-kapha nadi, 29% were having vata-pitta nadi 23% were having pitta kapha nadi. Thus it is observed that vata-kapha nadi is seen in maximum participants.

Jivha:

Amongst 150 participants 62% were having saama jivha whereas 38% participants exhibited nirama jivha.

Mootra:

Amongst 150 participants 36 participants (24 %) reported bahumootrata i.e. frequent urination. However (77.7 % of them) were pramehi.

Mala:

60% participants reported constipation. Detailed analysis of purishavaha srotas is mentioned in same chapter.

Sweda:

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05 Observations

Atee sweda was reported by 23% participants. Alpa sweda was reported by 29% participants.

Nidra:

Nidra alpata was reported by 30% participants.

Menstrual History:

43 out of 150 participants were females. 7 out of them reported history of menorrhagia & 13 reported oligomenorriga.

History of Major illness:

Participants reported history of diseases like Jaundice, typhoid, mumps, fracture, malaria, HTN, Diabetes.

Associated symptoms:

Dyspnea on exertion, pedal edema, weakness, vertigo, constipation, headache, and flatus were seen as associated symptoms.

Annavaha srotodushti hetu:

I. A. 1 Atimatrasya bhojanat: Out of 150 participants 51 (34%) have consumed this hetu 2-3 days per week. Whereas only 10% patients consumed this hetu rarely. The table & graph for detailed observations are shown below, where a, b, c, d & e stands for Rare , 1/7 days , 2-3/ 7 days , 4-5/ 7 days & almost daily i.e. 6-7/7days respectively.

Frequency Percent A 15 10.0 B 19 12.7 C 51 34.0 D 25 16.7 E 40 26.7 Total 150 100.0

131

05 Observations

60 51

50 40 40

30 25 19 20 15

10

0 A B C D E

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 4 24.87 0.000

I. A. 2 Akale bhojanat: Out of 150 participants 49 (32.7%) have answered to this hetu in ‘mostly yes’ manner. The table & graph for detailed observations are shown below, where a, b, c, d & e stands for yes, not, mostly yes (i.e. more than 4/7), mostly no i.e. more than 4/7 & for having history of this hetu. Frequency Percent A 15 10.0 B 23 15.3 C 49 32.7 D 27 18.0 E 36 24.0 Total 150 100.0

132

05 Observations

49 50 45 40 36 35 27 30 23 25 20 15 15 10 5 0 A B C D E

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 4 26.41 0.000

I. A. 3 Ahitasya bhojanat :

Out of 150 participants 89 (59.3%) reported consumption of ahitakara bhojana (classical as well as modern day items) whereas 45 (30%) participants denied. 16 (10.7%) participants were previously undergoing the same hetu. Quantity of the ahitakara ahara ranged from minimal to as good as equivalent to main course.

Frequency Percent A 89 59.3 B 45 30.0 C 16 10.7 Total 150 100.0

133

05 Observations

89 90 80 70 60 45 50 40

30 16 20 10 0 A B C

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 2 18.12 0.000

Purishavaha srotodushti hetu:

I. B. 1 Purisha vega vidharanat: Out of 150 participants maximum 46 (30.7%) reported vegavarodha 2- 3 days in a week. The table & graph for detailed observations are shown below, where a, b, c, d & e stands for Rare , 1/7 days , 2-3/ 7 days , 4-5/ 7 days & almost daily i.e. 6-7/7days respectively.

Frequency Percent A 24 16.0 B 32 21.3 C 46 30.7 D 24 16.0 E 24 16.0 Total 150 100.0

134

05 Observations

50 46 45 40 32 35

30 24 24 24 25 20 15 10 5 0 A B C D E

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 4 22.83 0.000

I. B. 2 Atyashanat: Out of 150 participants 51 (34%) have consumed this hetu 2-3 days per week. Whereas only 10% patients consumed this hetu rarely. The table & graph for detailed observations are shown below, where a, b, c, d & e stands for Rare , 1/7 days , 2-3/ 7 days , 4-5/ 7 days & almost daily i.e. 6-7/7days respectively.

Frequency Percent A 15 10.0 B 19 12.7 C 51 34.0 D 25 16.7 E 40 26.7 Total 150 100.0

135

05 Observations

60 51

50 40 40

30 25 19 20 15

10

0 A B C D E

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 4 24.87 0.000

I. B. 3 Ajeernadhyashanat:

Ajeernadhyashana was reported almost daily by 52% patients. The table & graph for detailed observations are shown below, where a, b, c, d & e stands for Rare , 1/7 days , 2-3/ 7 days , 4-5/ 7 days & almost daily i.e. 6-7/7days respectively.

Frequency Percent A 15 10.0 B 24 16.0 C 39 26.0 D 20 13.3 E 52 34.7 Total 150 100.0

136

05 Observations

60 52

50 39 40

30 24 20 20 15

10

0 A B C D E

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 4 23.24 0.000

I. B. 4 Doorblagni: Out of 150 participants 92 i.e. 61% participants reported doorbalagni. Frequency Percent A 92 61.3 B 58 38.7 Total 150 100.0

137

05 Observations

92 100 90 80 58 70 60 50 40 30 20 10 0 A B

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 1 12.92 0.000

I. B. 5 Krushatwa: Krushwatwa was assessed by considering BMI of participants. Participants with BMI less than 18.5 were considered as krusha. 86 out of 150 patients were krusha.

Frequency Percent A 64 42.7 B 86 57.3 Total 150 100.0

138

05 Observations

86 90 80 64 70 60 50 40 30 20 10 0 A B

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 1 12.80 0.000

Agni dushti hetu:

I. C. 1: Abhojanat: Out of 150 participants 28% & 27% participants were having this hetu rarely or 0nce in a week. The table & graph for detailed observations are shown below, where a, b, c, d & e stands for Rare , 1/7 days , 2- 3/ 7 days , 4-5/ 7 days & almost daily i.e. 6-7/7days respectively.

Frequency Percent A 41 27.3 B 42 28.0 C 24 16.0 D 12 8.0 E 31 20.7 Total 150 100.0

139

05 Observations

42 45 41 40 35 31 30 24 25 20 12 15 10 5 0 A B C D E

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 4 22.81 0.000

I. C. 2: Vishamashana:

History of vishamashana was reported by 66.7% participants out of 150 participants.

Frequency Percent A 50 33.3 B 100 66.7 Total 150 100.0

140

05 Observations

100

100 90 80 70 50 60 50 40 30 20 10 0 A B

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 1 15.71 0.000

I. C. 3: Asatmya bhojana: History of asatmya bhojana was reported by 84.7% participants out of 150 participants.

Frequency Percent A 23 15.3 B 127 84.7 Total 150 100.0

141

05 Observations

127 140

120

100

80

60 23 40

20

0 A B

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 1 15.51 0.000

I. C. 4 : Guru bhojana:

Guru bhojana was assessed by asking frequency of following food items. Also write the frequency & quantity of them. Raj masha, Nishpva, kushmanda, Trapus, Alabu, Shami phala , Madhu, Buffalo milk/ ghee, milk derivatives like shreekhand, amrakhanda, basundi, pedha, malai sweets Paneer, dahi, mamsa, matsya, egg, maida derivatives like gulabjamun, mango juice, fried foods. 94 i.e. 64% patients were having history of guru bhojana.

Frequency Percent A 96 64.0 B 54 36.0 Total 150 100.0

142

05 Observations

96 100 90 80 70 54 60 50 40 30 20 10 0 A B

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 1 13.25 0.001

I. C. 5: Sheet bhojanat: Sheeta bhojana was reported by 34% participants in frequency of once in a week. The table & graph for detailed observations are shown below, where a, b, c, d & e stands for Rare , 1/7 days , 2-3/ 7 days , 4-5/ 7 days & almost daily i.e. 6-7/7days respectively.

Frequency Percent A 17 11.3 B 51 34.0 C 38 25.3 D 17 11.3 E 27 18.0 Total 150 100.0

143

05 Observations

60 51

50 38 40 27 30 17 17 20

10

0 A B C D E

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 4 15.32 0.000

I. C. 6: Ati rooksha bhojanat:

Ati rooksha bhojana was assed following food items if you consume them. also write the frequency & quantity of them. Yava, mudga, makustha, chanak, masoor, harenu, chanak , shimbi dhanya, Churmura, bread 98 i.e. 65% patients have history of ateerooksha ahara sevana.

Frequency Percent A 98 65.3 B 52 34.7 Total 150 100.0

144

05 Observations

98

100 90 80 70 52 60 50 40 30 20 10 0 A B

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 1 15.32 0.000

I. C. 7 : Sandushta bhojanat: 33% & 31 % participants have consumed rare or once in a week sandushta bhojana. The table & graph for detailed observations are shown below, where a, b, c, d & e stands for Rare , 1/7 days , 2-3/ 7 days , 4-5/ 7 days & almost daily i.e. 6-7/7days respectively.

Frequency Percent A 47 31.3 B 50 33.3 C 32 21.3 D 12 8.0 E 9 6.0 Total 150 100.0

145

05 Observations

50 47 50 45 40 32 35 30 25 20 12 15 9 10 5 0 A B C D E

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 4 17.76 0.000

I. C. 8: shodhana vibhrama: Shodhana vibhrama i.e. any complications of panchakarma therapy were assessed. Only 2% participants have shown history of such shodhana vibhrama.

Frequency Percent A 3 2.0 B 147 98.0 Total 150 100.0

146

05 Observations

147 160 140 120 100 80 60 40 3 20 0 A B

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 1 12.07 0.001

I. C. 9: Vyadhi karshanat: Vyadhi karshana i.e major weakness or weight loss followed by any disease was assessed. Only 36% participants shown history of vyadhi karshana by any major vyadhi.

Frequency Percent A 55 36.7 B 95 63.3 Total 150 100.0

147

05 Observations

95 100 90 80 70 55 60 50 40 30 20 10 0 A B

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 1 11.99 0.001

I. C. 10 : Vega vidharanat: Vegavidharana i.e. to suppress/ neglect natural urges like urine, yawning, sneezing , udgar, etc. was vegavarodha 2-3 days in a week. The table & graph for detailed observations are shown below, where a, b, c, d & e stands for Rare , 1/7 days , 2-3/ 7 days , 4-5/ 7 days & almost daily i.e. 6-7/7days respectively.

Frequency Percent A 34 22.7 B 36 24.0 C 46 30.7 D 24 16.0 E 10 6.7 Total 150 100.0

148

05 Observations

50 46 45 36 40 34 35

30 24 25 20 15 10 10 5 0 A B C D E

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 4 21.13 0.001

Annavaha srotodushti lakshana:

I. D. 1: Anannabhilasha: Feeling of anorexia i.e. you have an appetite but don’t have desire for food was assessed 30% participants reported it twice a week. The table & graph for detailed observations are shown below, where a, b, c, d & e stands for Rare , 1/7 days , 2-3/ 7 days , 4-5/ 7 days & almost daily i.e. 6-7/7days respectively.

Frequency Percent A 36 24.0 B 32 21.3 C 46 30.7 D 24 16.0 E 12 8.0 Total 150 100.0

149

05 Observations

50 46 45 40 36 32 35

30 24 25 20 12 15 10 5 0 A B C D E

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 4 14.59 0.001

I. D. 2: Aruchi: Aruchi i.e. inability to have food (because of tastelessness) in spite of having a desire for food was assessed. 34% participants reported it twice a week. The table & graph for detailed observations are shown below, where a, b, c, d & e stands for Rare , 1/7 days , 2-3/ 7 days , 4-5/ 7 days & almost daily i.e. 6-7/7days respectively Frequency Percent A 33 22.0 B 51 34.0 C 38 25.3 D 17 11.3 E 11 7.3 Total 150 100.0

150

05 Observations

60 51

50 38 40 33

30 17 20 11

10

0 A B C D E

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 4 21.13 0.001

I. D. 3: Avipak: Avipaka was judged it by having feeling of lightness, clean udgar, some vega of mutra/ mala, freshness/ enthusiasm as indicators of digestion. 30% participants reported twice a week. The table & graph for detailed observations are shown below, where a, b, c, d & e stands for Rare , 1/7 days , 2-3/ 7 days , 4-5/ 7 days & almost daily i.e. 6-7/7days respectively Frequency Percent A 36 24.0 B 32 21.3 C 46 30.7 D 24 16.0 E 12 8.0 Total 150 100.0

151

05 Observations

50 46 45 40 36 32 35

30 24 25 20 12 15 10 5 0 A B C D E

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 4 20.21 0.001

I. D. 4: Chhardi : Nausea / vomiting was reported by 69% participants it rarely. The table & graph for detailed observations are shown below, where a, b, c, d & e stands for Rare , 1/7 days , 2-3/ 7 days , 4-5/ 7 days & almost daily i.e. 6-7/7days respectively.

Frequency Percent A 104 69.3 B 21 14.0 C 15 10.0 D 9 6.0 E 1 .7 Total 150 100.0

152

05 Observations

120 104

100

80

60

40 21 15 20 9 1 0 A B C D E

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 4 20.13 0.001

Purishavaha srotodushti lakshana:

I. E. 1 : Krucchra Purisha : Kruchhra purisha i.e. pravahana (groan) for a successful excretion of fecus was assessed. 35% patients reported it twice in week. The table & graph for detailed observations are shown below, where a, b, c, d & e stands for Rare , 1/7 days , 2-3/ 7 days , 4-5/ 7 days & almost daily i.e. 6-7/7days respectively Frequency Percent A 33 22.0 B 9 6.0 C 53 35.3 D 24 16.0 E 31 20.7 Total 150 100.0

153

05 Observations

60 53

50

40 33 31

30 24

20 9 10

0 A B C D E

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 4 18.06 0.001

I. E. 2 : Alpalpa Purisha :

Is the quantity of purisha considerably less was assessed.58 % participants report yes. a) yes b) no

Frequency Percent A 87 58.0 B 63 42.0 Total 150 100.0

154

05 Observations

87

90 80 63 70 60 50 40 30 20 10 0 A B

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 1 10.45 0.001

I. E. 3 : Sashabda Purisha : Is there shabda i.e.some sound during mala pravrutti was assessed. 49% participants report this hetu rarely. The table & graph for detailed observations are shown below, where a, b, c, d & e stands for Rare , 1/7 days , 2-3/ 7 days , 4-5/ 7 days & almost daily i.e. 6-7/7days respectively

Frequency Percent A 74 49.3 B 22 14.7 C 31 20.7 D 15 10.0 E 8 5.3 Total 150 100.0

155

05 Observations

80 74

70

60

50

40 31

30 22 15 20 8 10

0 A B C D E

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 4 13.38 0.001

I. E. 4 :Sashoola Purisha : Is the process of defecation painful? If yes specify whether pain is anal/ lower abdominal? The table & graph for detailed observations are shown below, where a, b, c, d & e stands for Rare , 1/7 days , 2-3/ 7 days , 4-5/ 7 days & almost daily i.e. 6-7/7days respectively

Frequency Percent A 63 35.3 B 21 14.0 C 24 16.0 D 30 20.0 E 12 8.0 Total 150 100.0

156

05 Observations

70 63

60

50

40 30 24 30 21

20 12

10

0 A B C D E

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 4 13.34 0.001

I. E. 5 :Atee Drava Purisha : Is the constituency of purisha liquid ? 48 percent participants reported it rarely. The table & graph for detailed observations are shown below, where a, b, c, d & e stands for Rare , 1/7 days , 2-3/ 7 days , 4-5/ 7 days & almost daily i.e. 6-7/7days respectively Frequency Percent A 73 48.7 B 27 18.0 C 25 16.7 D 17 11.3 E 8 5.3 Total 150 100.0

157

05 Observations

80 73

70

60

50

40 27 25 30 17 20 8 10

0 A B C D E

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 4 13.28 0.001

I. E. 6 : Atee Grathita Purisha : Hard stools were reported by 21% participants whereas 23 & 22 5participants are having same for more frequency. The table & graph for detailed observations are shown below, where a, b, c, d & e stands for Rare , 1/7 days , 2-3/ 7 days , 4-5/ 7 days & almost daily i.e. 6-7/7days respectively Frequency Percent A 32 21.3 B 19 12.7 C 35 23.3 D 34 22.7 E 30 20.0 Total 150 100.0

158

05 Observations

35 34 35 32 30 30

25 19 20

15

10

5

0 A B C D E

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 4 17.67 0.001

I. E. 7 : Atee Bahu Purisha : 40% participants reported the quantity of purisha considerably more.

Frequency Percent A 61 40.7 B 89 59.3 Total 150 100.0

159

05 Observations

89

90 80 61 70 60 50 40 30 20 10 0 A B

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 1 13.13 0.001

Some more important lakshana of mahasrotas:

I. F. 1 Aasyavairasya: To the question, does u have complaint of tastelessness / altered tastes, 70 percent participants reported yes.

Frequency Percent A 105 70 B 45 30 Total 150 100.0

160

05 Observations

95

120

100

80 45 60

40

20

0 A B

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 1 17.57 0.001

I. F. 2 Amlak:

Do u suffer from amla udgar / amla udirana? 57% participants reported no to amlaka.

Frequency Percent A 64 42.7 B 86 57.3 Total 150 100.0

161

05 Observations

86 90 80 64 70 60 50 40 30 20 10 0 A B

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 1 17.54 0.002

I. F. 3 Urodaha Urodaha or chest burn was reported by 39% participants.

Frequency Percent A 59 39.3 B 91 60.7 Total 150 100.0

162

05 Observations

91 100 90 80 59 70 60 50 40 30 20 10 0 A B

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 1 10.01 0.002

I. F. 4 Udar daha Udara daha burning sensation in abdomen was reported by 71% participants.

Frequency Percent A 107 71.3 B 43 28.7 Total 150 100.0

163

05 Observations

107 120

100

80

60 43

40

20

0 A B

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 1 9.96 0.002

I. F. 5 Aadhman Aadhman i.e flatus in abdomen were reported by 57 %participants.

Frequency Percent A 86 57.3 B 64 42.7 Total 150 100.0

164

05 Observations

86 90 80 64 70 60 50 40 30 20 10 0 A B

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 1 12.85 0.002

I. F. 6 Aatop 50% participants reported from gud-gud sound in abdomen?

Frequency Percent A 76 50.7 B 74 49.3 Total 150 100.0

165

05 Observations

76

76 74 72 70 68 64 66 64 62 60 58 A B

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 1 9.91 0.002

I. F. 7 Aanah Anaha i.e. tension in abdomen & constipation was reported by 46% participants

Frequency Percent A 69 46.0 B 81 54.0 Total 150 100.0

166

05 Observations

81 82 80 78 76 74 72 69 70 68 66 64 62 A B

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 1 12.80 0.002

I. F. 8 Vishtambha Vishthambha i.e constipation as well as obstruction in passing of flatus was reported by 60% participants.

Frequency Percent A 90 60 B 60 40 Total 150 100.0

167

05 Observations

80

80 78 76 74 70 72 70 68 66 64 A B

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 1 9.84 0.002

I. F. 9 Gala vidaha

Galavidaha i.e. burning in throat was reported by 26% participants.

Frequency Percent A 40 26.7 B 110 73.3 Total 150 100.0

168

05 Observations

110 120

100

80

60 40

40

20

0 A B

Degree of freedom, Chi square & p value for this observation are: Chi- P- DF Square Value 1 6.53 0.011

Part II (A) (Pranavaha srotas Hetu Parikshana) Kshayat: II.A.1) irshya:

It was converted into gradations as a) No b) grade 1 c) grade 2 d) grade 3 e) grade 4

28% participants reported irsha of grade 4 whereas 21.3% reported of grade 3.

Frequency Percent A 31 20.7 B 29 19.3 C 32 21.3 D 42 28.0 E 16 10.7 Total 150 100.0

169

05 Observations

42 45 40 32 35 31 29 30 25 20 16 15 10 5 0 A B C D E

Degree of freedom, Chi square & p value for this observation are: Chi- P- DF Square Value 4 21.55 0.001

II. A. 2) Utkantha: It was converted into gradations as a) No b) grade 1 c) grade 2 d) grade 3 e) grade 4

32.7% participants reported no utkantha. However in 25% each it was found in grade 3& 4.

Frequency Percent A 49 32.7 B 29 19.3 C 22 14.7 D 25 16.7 E 25 16.7 Total 150 100.0

170

05 Observations

49 50 45 40

35 29 30 25 25 22 25 20 15 10 5 0 A B C D E

Degree of freedom, Chi square & p value for this observation are: Chi- P- DF Square Value 4 21.47 0.001

II. A. 3) Bhaya:

It was converted into gradations as a) No b) grade 1 c) grade 2 d) grade 3 e) grade 4

25.3% participants reported bhaya of grade 3. Whereas bhaya of grade 2 was found in 22.7 % participants.

Frequency Percent A 28 18.7 B 28 18.7 C 34 22.7 D 38 25.3 E 22 14.7 Total 150 100.0

171

05 Observations

38 40 34 35 28 28 30

25 22

20

15

10

5

0 A B C D E

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 4 19.69 0.001

II. A. 4) Shoka

It was converted into gradations as a) No b) grade 1 c) grade 2 d) grade 3 e) grade 4

22% participants reported Shoka of grade 3 & 2. Almost 20% participants reported no shoka as well as shoka of grade 4.

Frequency Percent A 30 20.0 B 33 22.0 C 34 22.7 D 24 16.0 E 29 19.3 Total 150 100.0

172

05 Observations

33 34 35 30 29 30 24 25

20

15

10

5

0 A B C D E

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 4 21.70 0.001 II. A. 5) Krodha:

It was converted into gradations as a) No b) grade 1 c) grade 2 d) grade 3 e) grade 4

Almost 23% participants reported no Krodha as well as same percentage of participants reported Krodha of 3rd grade. 24.7% participants had krodha level of second degree

Frequency Percent A 35 23.3 B 21 14.0 C 37 24.7 D 35 23.3 E 22 14.7 Total 150 100.0

173

05 Observations

Degree of freedom, Chi square & p value for this observation are:

37 40 35 35 35

30

25 21 22

20

15

10

5

0 A B C D E

Degree of freedom, Chi square & p value for this observation are: Chi- P- DF Square Value 4 19.53 0.001

II. A. 6) Anashana Out of 150 participants 28% & 27% participants were having this hetu rarely or 0nce in a week. The table & graph for detailed observations are shown below, where a, b, c, d & e stands for Rare , 1/7 days , 2- 3/ 7 days , 4-5/ 7 days & almost daily i.e. 6-7/7days respectively. Frequency Percent A 41 27.3 B 42 28.0 C 24 16.0 D 12 8.0 E 31 20.7 Total 150 100.0

174

05 Observations

42 45 41 40 35 31 30 24 25 20 12 15 10 5 0 A B C D E

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 4 22.81 0.000

II. A. 7) Ati maithuna : Out of 150 participants maximum 62% reported ati maithuna. Whereas 37 % participants denied it.

Frequency Percent A 94 62.7 B 56 37.3 Total 150 100.0

175

05 Observations

94 100 90 80 70 56 60 50 40 30 20 10 0 A B

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 1 21.47 0.000

II. A. 8) Sandharanat: Out of 150 participants maximum 46 (30.7%) reported vegavarodha 2- 3 days in a week. The table & graph for detailed observations are shown below, where a, b, c, d & e stands for Rare , 1/7 days , 2-3/ 7 days , 4-5/ 7 days & almost daily i.e. 6-7/7days respectively.

Frequency Percent A 34 22.7 B 36 24.0 C 46 30.7 D 24 16.0 E 10 6.7 Total 150 100.0

176

05 Observations

50 46 45 36 40 34 35

30 24 25 20 15 10 10 5 0 A B C D E

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 4 21.13 0.001

II. A. 9) Raukshyat: Out of 150 participants maximum 58% reported raukshya.40% were not fulfilling the criteria. Frequency Percent A 88 58.7 B 62 40.7 Total 150 100.0

177

05 Observations

88

90 80 61 70 60 50 40 30 20 10 0 A B

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 1 20.21 0.000

II. A.10) Vyayamat Kshudhitasya: 46% participants reported exertion/ exercise inspite of being kshudhita.

Frequency Percent A 70 46.7 B 80 53.3 Total 150 100.0

178

05 Observations

80

80 78 76 74 70 72 70 68 66 64 A B

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 1 10.45 0.001

II. A.11) Darun karma: Out of 150 participants maximum 65% reported daruna karma as a history.

Frequency Percent A 98 65.3 B 52 34.7 Total 150 100.0

179

05 Observations

98

100 90 80 70 52 60 50 40 30 20 10 0 A B

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 1 10.36 0.001

Part II (B) (Rasavaha srotas Hetu Parikshana)

II. B. 1) Guru:. 64% participants were reported to have history of guru bhojana.

Frequency Percent A 96 64.0 B 54 36.0 Total 150 100.0

180

05 Observations

96 100 90 80 70 54 60 50 40 30 20 10 0 A B

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 1 13.25 0.001

II. B. 2) Sheeta: Sheeta bhojana was reported by 34% participants in frequency of once in a week. The table & graph for detailed observations are shown below, where a, b, c, d & e stands for Rare , 1/7 days , 2-3/ 7 days , 4-5/ 7 days & almost daily i.e. 6-7/7days respectively.

Frequency Percent A 17 11.3 B 51 34.0 C 38 25.3 D 17 11.3 E 27 18.0 Total 150 100.0

181

05 Observations

60 51

50 38 40 27 30 17 17 20

10

0 A B C D E

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 4 15.32 0.000

II. B. 3) Ati snigdham: 58% participants have reported snigdha sevanam.

Frequency Percent A 88 58.7 B 62 41.3 Total 150 100.0

182

05 Observations

88

90

80 62 70 60 50 40 30 20 10 0 A B

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 1 13.16 0.001

II. B. 4) Ati matram: Out of 150 participants 51 (34%) have consumed this hetu 2-3 days per week. Whereas only 10% patients consumed this hetu rarely. The table & graph for detailed observations are shown below, where a, b, c, d & e stands for Rare , 1/7 days , 2-3/ 7 days , 4-5/ 7 days & almost daily i.e. 6-7/7days respectively.

Frequency Percent A 15 10.0 B 19 12.7 C 51 34.0 D 25 16.7 E 40 26.7 Total 150 100.0

183

05 Observations

60 51

50 40 40

30 25 19 20 15

10

0 A B C D E

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 4 24.87 0.000

II. B. 5) Chityanam cha ati chintanat: 69% participants reported this hetu.

Frequency Percent A 104 69.3 B 46 30.7 Total 150 100.0

184

05 Observations

104 120

100

80 46 60

40

20

0 A B

Degree of freedom, Chi square & p value for this observation are:

Chi- P- DF Square Value 1 10.45 0.001

Summury of Observations:

 All of 3 factors of Annavaha srotas dushti hetu show significant relation.  Three factors of Purishavaha srotas dushti hetu whereas ‘krushtwa’ shows significant relation.  Six factors of agni vitiation Abhojana, guru, rooksha, sheeta, sandushta bhojana & vega dharana show significant association. Whereas 4 lakshana i.e. Vishamashana & Asatmya bhojana, Shodhana & vyadhi karshana show non-significant relation.  3 lakshana of annavaha srotodushti i.e. Annanabhilasha, Aruchi, Avipak show significant association whereas chhardi show non-significant relation.

185

05 Observations

 Three Lakshana like atigrathita, alpalpa & krruchhra purisha are seen in significant association whereas 3 sashabda, sashoola & ate bahu purisha lakshana are seen in non- significant relation.  Lakshana like Aasyavairasya, Udar daha, aadhman, aatop, aanah, vishtambha, Gala vidaha are seen in significant relation. Whereas amlak & urodaha do not show significant relation.  Among manas bhava, 4 of them Irshya, bhaya, shoka, krodha show significant relation. Whereas hetu, utkantha shows non- significant relation.  Pranakshyakara hetu like Ati maithuna, sandharana, raukshya, Kshudhitasya vyayama, Daruna karma show positive association whereas anashana shows non-significant relation.  All of 5 Rasa dushti hetu Guru bhojana, Sheeta bhojana, Ati snigdham, Ati matram, Chintyanam Ati chintana are seen in significant relation.

Thus it can be seen that so far as hetu are considered annavaha srotodushti & rasavaha srotodushti are seen 100% & they are followed by dushti hetu of purishavaha & pranavaha srotas. Agni dushti hetu are at last to be seen associated.

Annavaha dushti lakshana & Purishavaha dushti lakshana are seen associated with CHD, Purishavaha srotas dushti lakshana are also seen associated.

186

Discussion

All sciences deal in unity. They unite phenomena in a principle. (William T Harris) 06 Discussion

Discussion

It comprises two subchapters:

1) Discussion on Conceptual part:

2) Discussion on CHD & Observational study:

187

06 Discussion

1) Discussion on Conceptual part: a) Conceptualization of Prana & its Relevance with contemporary health sciences b) Subtle prana: Guna/Attributes & corollarial functions c) ‘Prana - rakta – agni’: Interrelationship d) Subtle prana & yogik/darshnik concepts & manas e) Few concluding remarks on Concept of Subtle Prana & Prana vayu f) Discussion on Physiological interrelationship of ‘Hrudaya’, ‘Mahasrotas’ & ‘Prana’ g) Hrudaya- Prana- Mahasrotas Interrelationship

188

06 Discussion

a) Conceptualization of Prana & its Relevance with contemporary health sciences:

Any systematic approach to Biology and Medicine shall ideally be based on ontological & epistemological principles.

1

Prana is considered as notion of vitality in oriental sciences. Vitality and vigor are considered synonymous; both refer to the presence of energy, enthusiasm and the absence of fatigue, weariness, and exhaustion. However "aliveness" is the more appropriate translation of word vitality.

This notion of vitality is in use of many scholars worldwide. It has different meanings in different doctrines. Vitality refers, in ecology, to the success of an organism in translating nutrients or other inputs into growth.2 In neuro-biology, cognitive vitality refers to the brain's ability to adapt and learn.3

Unfortunately notion of vitality is not given due importance in contemporary biology or health sciences & is neither explored to the extent it is expected to be. William Allison has reported that, „notion of vitality is not only admissible in physiology but itself entitles a name of separate science.‟ He has observed that those physiologist who object usage of term vitality are in fact obliged to use vital as a adjective which conveys the very same idea.4

Although vitality means liveliness but, „what exactly life is?‟ Life & Health are not mere words but are the terms/ concepts defined & criticized over hundreds of years by scholars of different doctrines. There is need to write criticism on „life‟ vis a vis „prana’, because „Desire for life‟ is mentioned as „Praneshana’ in Charaka Samhita & thus prana is considered equivalent with life. „What is life‟, is indeed most enigmatic questions & is attempted by different scholars of various doctrines.

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06 Discussion

Today in western biosciences there is no unanimously accepted definition of life & many of definitions of life are contradictory with one another. Popa (2004) & Barberi (2003) compiled (90 & 60 definitions respectively) & analyzed different definitions of life, in their compilatory works.5

Trifonov analyzed all of 123 definitions of life & attempted to make a minimalistic one. He has echoed Darwin‟s (Life is self reproduction with variation) & Oparin‟s definitions. (Any system capable of replication & mutation is alive) As a minimalistic definition of life he proposed, „Life is [System, Matter, Chemical (Metabolism), Complexity (Information), (Self-) Reproduction, Evolution (Change), Environment, Energy & Ability] where the square brackets correspond to some compact expression containing the words listed within.‟6 His attempt of making consensus over definition of life was criticized by many scholars. Clarifying difference between „change‟ & „mutation‟, Benner explained how „reproduction with variation‟ is not an acceptable definition of life, because crystals grow, incorporating defects; and they reproduce when powdered and used to seed the growth of more crystals. What crystals lack is heritability, as in Darwinian evolution.7 Bernstein a physiologist pointed out that Darwinian evolution requires not just “reproduction with variations” or “replication with mutation” but also critically a non-random selection.8

Taking a dig in prehistoric era, Szostak brought it to notice that according to Mineralogists9 Life and minerals have co-evolved. It is estimated that earth had ~1500 minerals before the origin of life, increasing to ~4300 minerals as on today & most of them may be as a result of biochemical processes. In another words, Szostak pointed out that understanding life is „to understand the transitions that led from chemistry to biology‟.10 Underlining complexity of life Yeong Foong has criticized that mere words like organization /complexity are not enough

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06 Discussion efficient. 11Because as reported by Oyama12 „the development of a multicellular organism, a more than the information encoded by genes. The interaction among cells as well as how cells will interact with its environment becomes much critical during development to ensure the proper unfolding of the resulting organism.‟

Questioning on essentiality of criterion of „metabolism‟ as a distinctive feature of life, Akkerhuis objected that , „a frozen bacterium still pos- sesses the structure of life, which can be demonstrated when it resumes living activity after being thawed.‟13 Let‟s keep that case of frozen bacterias apart, but „thawing‟ frozen embryos & transferring them as a part of ART (artificial reproduction techniques) is a common practice in today‟s IVF centers. In fact some observational studies report better obstetric and perinatal outcomes in pregnancies arising from the transfer of frozen thawed IVF embryos against fresh embryo transfers.14 Is that frozen embryo is alive is the real question. Although the frozen embryo do not show metabolism, it is capable of same in future.

Thus it is clear that there cannot be consensus over definition of life. However there can be some consensus over list of processes. There is need to understand that word „life‟ is used to describe organization, whereas „living‟ is used in relation to the dynamics of those organizations representing life. This differentiation was recognized by the famous Société de Biologie in Paris. The society had concluded: “La vie, c‟est l‟organisation en action”. Simply meaning, „living‟ refers to the dynamics of organization(s) that represent life.15 Thus the life processes can be listed like:

 Living things tend to be complex and highly organized.

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 They have the ability to take input of energy from the environment / ecosystem and transform & utilize same for growth and reproduction.  Living creatures respond, and their stimulation fosters a reaction- like motion, recoil, and in advanced forms, learning  Life is reproductive, as a kind of copying is must for evolution to take hold through a population's mutation and natural selection.

It is Cleland Carol (astrobiologist NASA) to uniquely quote the most distinctive feature of life. While defining life he reports, „…. organisms tend toward homeostasis: an equilibrium of parameters that define their internal environment…..‟16 Mention of „homeostasis‟ by Carol perhaps makes the „definition of life‟ a step ahead towards correct one.

In ayurvedic epistemological viewpoint, „aayu’ is nothing but „jivitkala’ i.e. span until one is alive. Also in Ayurvedic viewpoint viyoga of prana is nothing but death. Thus life & death are intimately related with prana vayu & subtle prana. Although situated in all organs & tissues subtle prana is particularly resided in marmas, ten pranayatana & along with rakta as reviewed previously. In addition Bhavamishra specifically mentions shukra, rakta & mala as site of „jiva’ in sharir.17

While discussing subtle prana as a vitality element, one must note that there is no some „structural element‟ of vitality as such that is resided in those tissues/organs. The meaning of being „vital‟ simply implies role of confined physiology of that organ. Appropriate regulation of metabolism of that organ/tissue results in preservation of prana element and continuation of prana & thus life.

It is very important to note that life is a process & not a system. In Ayurvedic viewpoint term „ayu’ itself means, „one that goes on continuously.‟ Gati & Gandhana both are meanings of root word „va’, again implies the meaning, „being in motion‟. This life process is nothing

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06 Discussion but equilibrium of many of opposite phenomena. Homeostasis a distinctive feature of aliveness & that of health is analogous with samayogavahitwa. Ayurvedic definition of sharir is not only union of satwa (manas), aatma & sharir but a samayogavahi union. Although all of panchamahabhoota have opposite kind of attributes, they do not act so as to nullify each other so as in living body. In a living body mahabhota opt mode of „anyonya ashraya’ instead of „anyonya abhibhava „. Thus it is presence of aatma & soul that makes one living. This integration of mind and consciousness with the human body, makes Ayurveda different from biomedicine‟s Newtonian physics-based perception of the organism as a structural entity made up of fundamental units of building blocks, that is, atoms and molecules.18

Distinctive features of life process above mentioned, show association with „prana physiology‟. The comprehension can be summarized in the tabular form as:

Domain Distinctive life process Role of Prana

Physiology complex and highly organized Samayogavahi as a distinctive feature of sharir in its alive state Physiology/ to take input of energy from Nutrition of Biology the environment / ecosystem „aabhyantar prana’ (12 and transform & utilize same prana ) by input of for growth of body mass „bahya prana’ (Sushruta) Physiology/ Appropriate shading of  „Mala’: Place of Biology biomass jiva/ prana (Bhavaishra)  Guda, Basti

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(pranayatana) Physiology/ reproductive, ( with Shukra as a Biology replication as a part) with pranayatana mutations and natural selection Physiology Homeostasis/ Adaptibility Samayogavahi as a distinctive feature of sharir in its alive state Physiology Higher functions  Function of Prana: Chitta Dharana, Buddhi, indriya dharana Ojus (pranayatana) responsible for higher manas function Psychology Subjective vitality (Ryan &  Function of Frederick 1997) Prana: Chitta Dharana  Ojus (pranayatana) responsible for higher manas function Ecology translating nutrients or other Prana-Agni inputs into growth interdependence Neuro biology the brain's ability to adapt Function of Prana: and learn Buddhi, indriya dharana Moordha place of prana

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In western biomedicine‟s viewpoint these different life processes are acknowledged with different systems & organs. However „theory of prana’ can form as a common ground for all of them as shown in table. While addressing complexity in biology Mazzocchi F has very precisely pointed out that, „ there is need for both the approaches – holistic as well as reductionist with detailed understanding of „whole‟ and the „parts‟. There is growing consensus to accept the complexity theory and need to exceed limits of reductionism‟19

Prana & Pneuma:

As reviewed previously, concept of pneuma is found analogous with concept of prana. Interestingly there are three grades/ types of pneuma, depending on their percentage of fire and air.20

The pneuma of state: This unifying and shaping pneuma provides stability and cohesion to entities. An individual is defined by the equilibrium of its inner pneuma, which holds it together and also separates it from the world around it. This shows resemblance with concept of prana, ojus & prakruta kapha. „Tantra-Yantradhara’ (holding body components & regulating its operations) & ‘sandhanakara’ are functions of prakruta vata/ Prana.

The pneuma as the life force: The vegetative pneuma enables growth and distinguishes a thing as alive. In ayurveda, shukra dhatu responsible for all reproductive activities in body is considered as pranayatana.

The pneuma as soul: The pneuma in most rarefied/ fiery form is known as the animal soul (psychê); it encompasses the organism, governs its movements, and endows it with powers of perception and reproduction.20 Concept of prana as a aatma guna is resembling with same.

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In an surprising equivalence with „Prana-Agni’ relationship in, pneuma the concept of the "breath of life," is also considered to be a mixture of the ‘elemental air‟ (in motion) and „fire‟ (as warmth).21

‘Prana’ the energy behind Homeostasis? :

Good health & life itself are completely dependent on excellent communication between components of the body at the system, organ, cellular, molecular, atomic, and quantum levels, & thus on homeostasis. Ayurvedic classification of dosha dhatu & mala is a function based classification & thus implies homeostasis. Different body components connected by prana are coordinated with each other & health is maintained. Emeritus Prof R H singh has reported that, „I am inclined to suggest that if each one of the seven Dhatus are separated from the body what remains behind is the energetic life process ie the Prana which is the coordinating force for all structural and functional attributes in a quantum manner.‟22

Inspite of so much of research & advances very much less is known about how exactly the equilibrium is maintained in neurotransmitter networks / immune system, which has both hard-wired & humoral central nervous system connections.23 „Homeostatic capacity‟ is again a newer term. Homeostatic capacity refers to the inherent ability of the body to self-stabilize in response to external and internal stimuli. Homeostatic capacity of the human body erodes with age.24 This homeostatic capacity can be analogous with ones prana i.e. life energy levels.

Concept of prana & mammalians:

Chakrapani & Yogindranath sen both commentators of Charaka have clarified that „pranabhruta’ (one having prana) term refers to mammalians only.25 The distinctive features of mammalians can again be

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06 Discussion correlated with concept of prana. Mammals receive nutrition by placenta whereas nabhi is an important site of prana. Mammals have larger lung surface area assisted by diaphragm , have separate chambers (in heart) for oxygenated & deoxygenated blood & deliver only oxygenated blood to tissues. In Ayurvedic physiology, Prana is intimately related with heart & respiratory mechanism & is circulated with rakta. Mammalian kidney are exceptionally able to concentrate waste products in small amount of urine. Basti is considered as pranayatana & mala are said to be place of jiva/prana by Bhavamishra as quoted earlier.

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b) Subtle prana: Guna/Attributes & corollarial functions:

Any discussion in Ayurvedic biology & medicine is needed to be done in terms of „guna’ (attributes), sharir guna in particular. Guna/ attributes are most important tool, as Charaka mentions guna prior to dravya while enlisting six padartha.26 Samanya & vishesha are interpreted in terms of guna only, as quoted by Charaka. Gunas those are present in the drugs and body are one and the same. And hence the drugs having analogous gunas are responsible for the normalcy (health/sthana) and abnormalcy (kshaya/vruddhi) of the body constituents says sushruta.27 Vitality element subtle prana is related with all of sharir guna. Closely associated guna are discussed below.

Snigdha/ Vikasi:

Snigdha is first & foremost guna so far as nature & nourishment of subtle prana is considered. „Purusha is made from rarified extracts sneha and „Prana’ (vayu & subtle prana) is „snehabhooyishtha’ & hence his diseases can be well cured by sneha kalpana’, proposes Sushruta.28 Snigdha is a common guna between shukra & rakta the where in both dhatu are pranayatana. Snigdha guna leads to snehana, mardava, bala & varna.29 Snigdha as attribute of ahara leads to better taste of food & upsurge in agni, says Charaka in vimanasthana. It (snigdha guna) also leads to anulomana of vata, upachaya of sharir, strengthening of indriya & increase in bala & varna. In grahani dosha chikitsa Charaka has mentioned that only sneha is the best drug/entity to empower agni.30 The therapy of snehana improves & boosts prana principle in a individual says Charaka.31 Snigdha Guna causes Srotomardavata & thus facilitates entry of bhava padartha in respective srotas which is function prana as concluded in review chapter. But in abnormal forms it may lead to Abhisyanda. And can result in Sanga pradhana Srotodusti & thus in vitiation of prana. This is why excess sneha becomes reasons for

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Rasavaha and Raktavaha Srotodusti.32 Tark samgraha defines snigdha as, ‘Snehadi pindibhava snigdham’ & thus implies maintenance of cohesion of body parts (at different levels of organization, joints, and membranes). These sites of cohesion of body parts are nothing but sandhi (which is a moola sthana of majjavaha srotas an important snigdha dhatu). Thus sandhibandhna is maintained & continuance of prana is facilitated. Annihilation in sandhi bandha is caused by vikasi guna. In visha chapter Charakacharya explains, „it is because of vikasi attribute visha becomes pranaghna (leading to loss of prana element)‟33 Explaining term „vikasi’, Chakrapni further clarifies that the word is derived from root word kas meaning himsa i.e. violence. By implication this term means excessive violence or suppression of ojus.34 Vruddha Vagbhata has further explored that, Vikashi attribute leads to split the sandhi bandha. Vyavayee is sara pradhana & vikasi is teekshna pradhana.35 In Sushrutacharya‟s view, „Vikasana is prasarpana i.e. moving all over body & causing destruction of sandhi bandha’.36 Dhatu bandha vimoksha is nothing but dhatu shaithilya clarifies Dalhana.37 Thus integrity of body tissues/ elements in structural as well as functional quantum manner is maintained by snigdha guna. Thus pair of „Snigdha /Vikasi’ guna is pivotal in context with nourishment/ vitiation of subtle prana.

It is important to note that ksheena agni rapidly diminishes subtle prana whereas sthira & soma attribute ably preserves/ nurtures subtle prana i.e. avalambana of prana.

Soma/ Ushna: In context with vaikalyakara marma, Sushrutacharya have mentioned that Soma guna leads to sthiratwa, shaitya & thus contribute in continuance of prana.38 „Lhadana’ & „moorcha nashana’ are uniquely quoted as actions of sheeta guna by Sushrutacharya.39 Lhadana

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06 Discussion is „sukhkari’ explains Dalhana.40 Moorcha is a disease of raktavaha srotas & mastulunga. Thus it is sheeta attribute that nourishes subtle prana by smoothening manas & rakta dhatu & „moordha’ main seat of prana. In Charaka samhita grahani chikitsa Gangadhara has quoted that elemental prana is „aapomayam’ & vak is related with teja.

Sheeta guna results in contraction of body channels/srotas whereas Ushna guna results in dilatation of srotas. This equilibrium of sheeta & ushna guna leads to appropriate preservation of lumen in the body channel. Ushna guna is mainly for sthoola & sookshma pachana, which is function of pitta dosha & in turn that of rakta dhatu being aashrayee dhatu for rakta. Ushna guna is capable of liquefying body elements. It can digest aama & is able to remove plaques/adhesions/occlusions in body channels & facilitate srotas to work properly & thus restores vitality. As reviewed previously subtle prana depends on agni.

Thus equilibrium in pair of „sheeta-ushna’ guna results in maintaince of prana.

Manda/ Teekshna:

Manda guna leads to dullness in actions & resistance to change in status.41 Ayuh is a continuum of a perpetual motion that starts at time of conception and ends at the time of death. Faster the conversion of potential energy to kinetic energy, lesser will be the life span. This is why almost all of rasayana (drugs those are capable of arresting aging phenomenon) are capable to act with this manda attribute, reports Vd. Nanal Vilas.42

On the contrary, teekshna guna results in bhedana i.e. breaking thing into small pieces. This action of teeshna guna is helpful in process of pachana of dosha & for separating vitiated dosha from dhatu so that they

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06 Discussion can be brought in to koshtha for panchakarma. However excess of teekshna guna can result in dhatu paka & qualitative & quantative depletion of dhatu the structural units of sharir. Charakacharya has precisely mentioned that, „It is because of teekshna guna, visha becomes marmaghna i.e. causes injury to marma (which are site of prana).9

Thus pair of „manda / teekshna’ is related with ability of continuity of life processes.

Thus physiology of Subtle prana (vitality element) in context with essential guna can be presented like:

Basic guna needed for prana dependent continuum of 'ayuh' in perpetual motion:

fuel of 'snigdha' Guna (In Aptly dilated Srotas by Inertia of 'Manda' guna apt quantity ) for thirteen 'Ushna/Sheeta' for continuity of life agni & metabolism eequlibrium processes

Subtle prana is energy; it resides in pranayatana (organs) & dhatu (tissues). Prana is dependent on agni for its sustenance. Agni in turn depends on Snigdha, sheeta & manda element which is majorly found in Dhatu. This forms core triangle of Ayurvedic Physiology.

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Prana: Vitality Element

Soma, Snigdha, Manda: Sharir Agni dhatu/ Pranayatana (all 13 types)

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c) ‘Prana - rakta – agni’: enigmatic Interrelationships

Prana- Agni relationship:

As discussed in first subchapter of discussion, „Receiving input from environment & utilizing it for production of energy, growth in bio-mass & reproduction is a distinctive feature of a living process.‟ Sushrutacharya‟s theory of ‘bahya & aabhyantar’ prana is relevant with same.

43Dalhana has equated aabhyantar prana with bala as bala depends on sharir guna like dardhya which in turn depend on upachaya resulted from appropriate aahara. Ahara is considered as bahya prana as reviewed previously. Commentator Lakshamana precisely mentions role of „preenana’ attribute in resulting prana dharana.44 Vagbhatacharya quotes that timely taken food is brought in koshtha by prana vayu.45 Ahara pranayana is said karma of prana vayu by Charakacharya.46

After aahar (any respective nutrient) been brought in srotas, it is subjected to particular agni. After pachana (sthoola & sookshma) that nutrient gets converted in bodily form & becomes substance for aabhyantar prana. This desired force of agni is again dependent on prana.

Charakacharya quotes that person‟s bala, aarogya, aayu & prana depend of agni & by fuel of anna & paana, the agni becomes prajwalit or manda.47 While commenting on this verse Chakrapani clarifies that here Prana is a vayu as well as dasha pranayatana.48 Thus it is important to note that chakrapani gives importance to both, „prana vayu’ as well „subtle prana’, or aashrayee (prana) & aashaya (pranayatana) in context of „prana & its dependence on agni.‟

Pittadhara kala- Majjadhara kala:

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Ayurvedic sharir considerations are more functional than structural. Dalhana (while commenting on transport of visha through different organs/ tissues) has mentioned association between pittadhara kala & majjadhara kala.49 Pittadhara kala is located in grahani the main seat of agni & Majjadhara kala at moordha/ mastulunga.

While describing visha vega of darvikara sarpa Sushrutacharya have quoted that visha in its 5th vega enters asthi & vitiates prana & agni. Symptoms like parvabheda, hikka, daha are seen.50 Here again prana & agni are coined together & symptoms parvabheda denote majja dushti & hikka denote prana dushti. According to classification of Vruddha Vagbhata, among seven layers of twak, sixth layer is named as ‘pranadhara’ twak. If it gets cut lakshana like tama, aandhya & arunshi may arise. It is blakish red in colour & diseases of this are difficult to treat.51 Here also tama & aandhya are symptoms of vitiation of majja. Thus again substantiate the prana-agni relationship.

Prana-rakta Relationship:

It is known that along with the evolution of the living organisms, the involvement of oxygen & iron in the life process has become significant.52 Mammals deliver only oxygenated blood to organs with help of hemoglobin a iron compound. This is why most scholars are seen persuaded to translate ‘rakta’ with „blood‟. However one must understand the similarity & dis similarity between rakta & blood. Rakta is a dhatu generated from rasa dhatu after action of teja mahabhoota & ranjaka pitta (situated in aamashaya/ yakrut) & it gives aashraya to pitta dosha. Whereas blood is a liquid connective tissue (for transport of oxygen, nutrients etc) engaged in pulmonary, portal & systemic circulations. The oxygenated blood that is delivered via arteries is best translated by patwardhan kishor as a mixture of four entities: 1) “Rasa” (often wrongly translated as “Chyle”), the nutrient fluid that nourishes

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06 Discussion rest of the tissues; 2) “Rakta,” the red coloured fraction that is very essential for life processes; 3) “Ojas,” a white coloured fraction, functions of which are closely resemble immunity; and 4) “Prana,” a fraction derived through the act of respiration.53

Prana and subtle prana are very closely (anvaya-vyatireka) related as reviewed previously. Rakta is not only site of prana (pranayatana) but subtle prana is circulated via rakta, Jeevana as a function of rakta dhatu, implies the same.54 In fact this is why kshaya-vruddhi of all dhatu depends on „rakta dhatu’ 55 Sparsha dnyanam (tactile function) a function of nervous system as in biomedical viewpoint is function of shuddha rakta, as quoted by Sushrutacharya. Not only in case of tactile function, but also Moorcha56 (syncope), samoha57 are considered as raktapradosha vikara. This simply underlines the relationship of majja-prana-rakta.

Rakta-Prana-Poorana-Endothelium:

Poorana as reviewed previously is function of prana vayu. So far as rakta- prana relationship is concerned there is need to understand the importance of endothelium & nitric oxide. Endothelium the innermost layer of vessels is itself considered as an organ & is subject of a separate discussion. Nitric oxide is a endothelium-derived relaxing factor and is biosynthesized endogenously from semi-essential amino acid, L-argenine, molecular oxygen, and various nitric oxide synthase enzymes. NO is a key biological messenger playing an important role in various biological processes at the cellular level also contributing to nonspecific host defense against bacterial, viral, fungal, parasitic infections, hence takes care of infection in the body. Nitric oxide improves ventilation–perfusion ratio in the lung along with relaxation of bronchial tree smooth muscles, and thus oxygen uptake is increased and provides relief in bronchial

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06 Discussion asthma. Nitric oxide is also known to modulate nor epinephrine, serotonin, dopamine, glutamate, and the other major neurotransmitters involved in the neurological process. Stress reduces the release of nitric oxide. Horror movies reduce nitric oxide level whereas comedy movies increase nitric oxide level. Nitric oxide helps memory and behavior by transmitting information between neurogenic cells in the brain, apart from calming the brain by improving the quality of sleep. Some studies report „Nitric oxide may increase the recognition of sense that is speech discrimination improves the quality of hearing which goes down with the age.‟58

Yoga and meditation have appeared to improve endothelial function in subjects with CAD. Specific yoga techniques improve endothelial- dependent vasomotion in some studies.59Yoga practices are proved beneficial in coronary atherosclerosis & its prognosis.60 &61 Lipid lowering and plaque-stabilizing effects of yoga exercise seem to be similar to that of statin drugs (HMG CoA reductase inhibitors). Statin activity is associated with the increased production of nitric oxide in the vascular endothelium, which has local vasodilator properties in addition to anti- atherogenic, antiproliferative, and leukocyte adhesion-inhibiting effects. It is also known to enhance endothelium-dependent relaxation, inhibit platelet function, and inhibit the activity of endothelin-1, a potent vasoconstrictor and mitogen.62 Increased anxiety levels predict a worse endothelial function in patients with lifetime panic disorder.63

Thus the poorana karma of prana & rakta is seen analogous with perfusion function of endothelium.

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d) Subtle Prana Yogic/ Darshanik concepts & manas:

‘Sukha sandnyakam aarogyam’, Charakacharya‟s definition of health underlines importance of subjective feeling of wellbeing. Western biomedical fraternity has too revealed need for the same. To quote a latest Lancet editorial, „….Being more humble about the experience of individuals, rather than simply drawing up reductive report cards of their health status, opens up the possibility for a more realistic understanding of what it means to be healthy…‟64 While the World Health Organization‟s definition has not been amended since 1948, many scholars/scientists/health practitioners now accept that a transpersonal or spiritual dimension needs to be included. This reinforces that health is “wellness of all dimensions of the individual, and that the health of any one dimension is dependent on the maintenance of health on all other dimensions”65 Prana is the subtle entity that governs body as well mind & thus has got spiritual/ metaphysical & bio- energetic dimension. It is needed to be discussed as: a) Prana & pranayama & Yogic/Darshanik concepts b) Prana & Manas

Prana & Pranayama & Yogic /Darshanik concepts:

In yogic viewpoint „Prana’ is dispersed through the entire material & non- material world. In words of BKS Iyengar, „Prana is the energy permeating the universe at all levels. It is physical, mental, intellectual, sexual, spiritual & cosmic energy. All physical energies such as heat, light, gravity, magnetism & electricity are also prana. It is the prime mover of all activities. Vigor, power, vitality, life & spirit are all forms of Prana.66

“Prana is both macrocosmic and microcosmic and is the substratum of all life. Mahaprana (the great prana) is the cosmic, universal, all-

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06 Discussion encompassing energy out of which we draw substance through the breathing process”67 Author adds, „The moment prana leaves the body consciousness departs because prana and consciousness are the two poles of one source – the self”iii

As per Yogic concept of pancha kosha, the human is represented as having five inter-penetrating sheaths or fields that are corresponding to body, prana, manas (mind), knowledge, and bliss. As we shift from gross to subtle, laws of Physics turn out to be more generalized and more encompassing. That‟s why laws of Pranamya Kosha are seen more generalized than those of Annamaya Kosha (Physical world & physical body), those can be evaluated by modern physics. There is greater freedom for subtle particles of Pranamaya Kosha than molecules and atoms of the physical world.68

Interestingly it is a pranamaya kosha to bridge the annamaya kosha (panchabhautik body) & manas (mind). The pranic field permeates the whole body so that it‟s in contact with body, every cell in the body. Further, manas working through pranic field-could influence the cells through modulating the pranic field at any location in the body by mere thinking. When prana is inadequate, pain and other somatic problems arise; when prana leaves a site, death of the cells occur in that confined area.69

Although not used extensively, Pranayama is used as a therapy tool by ayurvedic acharyas at few places like hikka chikitsa & shalya removal chapters of Sushrut Samhita (sushruta uttar 15/16 & sushruta sutra 26/13.)

Pranayama & yoga based relaxation techniques & aasana are world wide accepted & practiced. According to yoga, by controlling the prana one can control the mind.70 In different studies yoga-based relaxation technique are proven to decreases state anxiety & depression.71 ,72, 73

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Some studies have also shown that yoga-based guided relaxation reduces sympathetic activity.74 Heart rate variability (HRV) was studied in individuals performing Cyclic Meditation. The study concluded considering to suggest increased vagal tone.75 Not only on psychosomatic components but yogic techniques are proven for grosser ailment like for healing of fractures.76 Interventions of some yoga based models ( by integrating the subtle aspects of mind (prana, mind and the self) into the psycho-neuro-immunological model of cancer) are observed effective in the management of breast cancer. Authors have reported need of „Mechanism studies‟ and „trans disciplinary dialogues‟ to consolidate concepts.77 Some optimistic scholars have reported that science is in a transition to believe biological systems fathomed with Prana an independent entity beyond mere functioning of deoxyribonucleic acid and ribonucleic acid molecules, taking into consideration a-brainal existence of mind, emotions and intellect.78 This transition to move beyond the physical in search of reality is a journey to understand Prana, mind, emotions, intellect and consciousness to bring them into the folds of scientific explorations.79

In rajayoga a yogi holds his breaths & thus distils his mind to increase subtle prana levels, ultimately leading to increased life span. This journey of gross to subtle & subtler levels is nothing but rajayoga. Aakasha-vayu-teja is a chronology in cosmogenesis, whereas in yogic processes it is from moorta to amoorta. i.e. pruthwi-jala-teja-vayu & akasha at the end80 Dnyaneshwari is the great commentary on bhagvadgeeta by saint Dnyaneshwar Maharaj. While exploring mystic sootras of sixth chapter of bhagvadgeeta, he explains that the shakti swaroopa kundalini (it is believed that a ‘shakti’ (energy) named ‘kundalini’ resides in ‘mooladhar chakra’ & moves towards ‘aadnya chakra’ during progress of rajayoga.) moves upwards & at the end it becomes „marut’ (vayu).81 This is an example of how teja gets converted

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06 Discussion into vayu. According to yogic considerations it is a journey beyond pranamaya kosha to aanandmaya kosha.

Many studies on analysis of interventions of yoga based techniques / pranayama & their evaluations in western biomedical perspective, are going on across the world. There is a need to make them more comprehensive with addition of ayurvedic considerations of pranayatana (the sites of subtle prana), concept of marma, rakta-prana relationship & role of prana vayu in perseverance of subtle prana.

So far as darshanik concept of prana is considered as it is partly physical & partly of conscious level. darshanik perception of Prana is as a vital breath or energy needed for actions in the form of elemental air & is characterized by consciousness & serves as a vehicle of spirit/ soul.

Vedanta perceives inner self/ conscious self / breath. Vaisheshika consider prana in light of mind & thus proposes that self consists with mind & is fastened with breath. Nyaya deals with prana in the light of purishik ether which is supported by breath & the senses themselves can be equated with prana. Sankhya examines prana in light of prakrutik energy. And thus prana can be perceived as (according to sankhya) energy of senses of action & is associated with action, as summarized by Thadani N.V.82

Prana & Electrons:

All biochemical processes are ultimately driven by electron transport. Electron is one of the fundamental particles in material evolution. It is postulated that electrons came into existence at an early stage of cosmogenesis when the universe went through a big bang and started cooling.83 Noble Laureate, Dr. Albert Szent-Gyorgyi states, “The living state is the electronically desaturated state of protein … Nature is simple

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06 Discussion but subtle…… Taking out electrons irreversibly means killing.”84 Srinivasan T M in an editorial of a journal (IJOY) has proposed probable equivalence of prana with electrons. According to him, the complexity we see in life forms around us could be due to the subtle property of oxygen to accept electrons.85 He further proposes, The ESR (electron spin resonance) signal is obtained as a result of formation of free radicals during normal metabolism or in some abnormal conditions. In normal individuals, the body usually flushes out these free radicals. In cancer, however, the involved proteins have a low degree of desaturation. It is stated, “any factor that inhibits charge transfer and the desaturation of protein has to be oncogenic and any factor that promotes these must be carcinogenic”xvi Author further points out phenomenon of the release of free radicals by the immune cells as a response to inflammation and the injurious effects posed by these free radicals to healthy cells and the availability of electrons from other sources like the earth that can establish homeostasis by reducing free radical activity. Needless to say, this proposed model of equivalence of prana with electrons has many limitations & needs to be validated at multiple levels.

Prana & manas:

Manas is an important & inevitable part of tripod of satwa, aatma, sharir. Subtle Prana the life principle carries sharir guna & sthoola panchabhautika sharir at one hand, whereas aatma guna & sookshma entities like manas, mahat & ahankar on other side. It is a coordinating force in fact. Several peer-reviewed scientific studies are used to demonstrate how the emerging field of PNIE i.e. „psychoneuroimmunoendocrinology‟ (Psychology–Neurology-Immunology- Endocrinology) might provide a link between yogic wisdom and modern science.86

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Pranamaya kosha is a coordinating kosha between annamaya & manomaya kosha. Thus linkage of body & mind is by prana. Again prerana of manas is function of prana vayu.

Thus there are mutual relationships of prana, manas & sharir. Impaired manas can impede functioning prana as well as sharir (pranayatana in particular). In a same way impaired subtle prana can impede functioning of manas & sharir (pranayatana in particular) Even western scientists are now proposing that, „Emotions can be equated with energy. Emotional activity and stimulus of any kind involve mobilization of electrical energy, as indicated on the galvanometer & both emotions and stimuli evoke the same energy.‟87 Emotions irshya, utkantha, bhaya, shoka, krodha in particular are said to be causative factors for depletion of subtle prana as reviewed in methodology chapter. They are discussed in subchapter of discussion on observational study. The relationship of manas & subtle prana is perfectly explained by a verse in Charaka Samhita sutrasthana. Ahimsa (nonviolence) is the greatest factor for preservation of subtle prana.88 Violence by manas leads to depletion of subtle prana & Nonviolence to continuation of same.

•External Annamaya •Sharir with special site of prana as pranayatana, kosha rakta, marma etc.

Pranamaya •Subtle prana kosha •The coordinating force

Manomaya •Internal •Emotions those can affect kosha remaining two layers

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e) Ontological & epistemological appraisal of Prana : Subtle Prana & Prana Vayu:

Although Ayurveda has accepted many theories from varied darshana shastras, Samkhya serves as backbone of ayurvedic fundamentals. Ayurveda is more influenced by samkhya where guna & karma are more important than vaisheshika where dravya is considered to be more important. In this view the vital element of subtle prana is needed to be interpreted in context with its guna & karma.

The thought of Respiration the prime indicator of life & the motivating force for existence of cosmos & humans remained pivotal in ancient oriental literature. Ancient Indians paid particular attention to process of respiration & body winds by making process of respiration a focus of religious concern & practice.89 As wind & breath are seen as representatives of macro & microcosmic life, earlier vedic literature. Later this equation of prana & its counterpart vayu is seen fused with sun or indra. This is simply because vayu could not be represented as highest cosmic ruler. Prana the purcesor or representer of aatman had to loose its connection with mouth nose & whole body, & became localized in heart in upanishada. It‟s purely vitalistic aspect decreased & was mixed with consciousness, observes Bodevitz.90 Thus the theory of prana is all together blending of Historical, philosophical & medical traces of concept of respiration & body winds in ancient vedic literature.

In ayurveda, interestingly, Prana is synonymous to Vayu. Concept of vayu as a dosha is in accordance with a functional entity. But along with that, prana is a term used as a vitality element of body. Vitality again depends on bala. This is why while describing the chapter of vatavyadhi chikitsa, Charakacharya have quoted a verse that says, „Vayu is the elan vitae, vayu is the strength, vayu is sustainer of body of living beings, vayu is all pervasive, it is reputed as controller of everything in the

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06 Discussion universe.‟91 Vayu is quoted synonymous to bala. Chakrapani clarifies it that, vayu is responsible for sharir dharana, Same sharir is the base for bala dharana. In such regards bala is synonymous to prana/vayu.92 Thus ontologically prana can be equated with subtle prana. This equivalence of prana with bala is reviewed previously. Mahesh TS et. al. have comprehended concept of bala at three levels. Firstly as a nourishing component that can be equated with local tissues like mamsa & generalized ones like ojus, kapha. Secondly as a generalized property of body which can be evaluated by vyayamshakti & vyadhi kshamatwa (immunity) & thirdly at level of energy i.e. life sustaining energy/ bioenergy.93 equivalence of bala & prana can be explored at three above mentioned levels like:

Bala : at three levels5 Subtle Prana Prana Vayu Gross Tissue mamasa, ojus, Pranayatana tissues Moordha & Ura level kapha & organs site of prana As Can be evaluated by: a) Vyayama as a) Prana for attribu a) Vyayama shakti vitiation & hrudaya te b) Vyadhikshamatwa demonstration dharana & factor of respiratory (all cardiopulmonary levels) processes efficacy b) Prana vayu b) Immunity: rakta, responsible for ojus, shukra as hrudaya, ojus, pranayatana. manas dharana/ prerana As Bio energy/ life energy Subtle prana, Prana vayu energy subjective vitality nurtures subtle prana

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In ayurvedic considerations term Ayuh itself is means, „one that goes on continuously.‟ Being a dynamic consideration it involves three kind of mechanism i.e. Mechanism for input, output and continuation of life. The contemplation of thirteen srotas in same regards where three srotas (anna, prana, udaka) are for intake, seven are for structural maintenance (dhatu) & three for excretion of mala.

Mahasrotas in view point of moolasthana of pranavaha srotas is reviewed previously. „The general treatment for pranavaha srotas resembles with disease shwasa which originates from amashaya. The term amashaya also mentioned as synonymous with mahasrotas. Shwasa originates in mahasrotas (Cha.Chi. 17). On account of this similarity and this clinical point of view mahasrotas as mulasthan of pranavaha srotas is justified here with.‟ (Panja asitkumar et.al)

„Ahara pranayana’ as a function of prana vayu is stated by Charaka. It does not merely imply transport of bolus from mouth to stomach, but is a wide ranging phenomenon. Ahara itself is a comprehensive term. There is role of prana vayu in all transport mechanisms of all respective nutrient bhavapadartha (ahara) in all respective srotas. This is why Sushrutacharya has mentioned poorna as karma of prana vayu while distinguishing types of vata dosha on basis of their functions.94 Dalhana has specified „poorana’ is expected to be done by ahara only.95 The term „Purana’ literally means Filling, Making full, Fulfilling, satisfying.96,97 „Pur’ is the root word in this case, which means „Palanpooranayoh’ i.e. to maintain & fill. Thus poorana of anna is filling for maintenance of sharir.

Vd. Nanal Vilas quotes that, „Thus action of prana vayu is to fill in vacant space. And it is either by absorption generating space or by secretion of different constituents.‟98,99

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Bruhattrayeeratna Nanal Ramesh has reported that action of Prana vayu is centrifugal.100 Thus centrifugal action leads to dilatation of srotas & facilitates poorana.101 For the phenomenon of dilatation of srotas there is need of ushna guna. As the definition implies ushna guna results in swedana. Thus it is agni which is responsible for apt dilatation of different body srotamsi & thereby facilitation of prana. In these regards mahasrotas (site of agni) is considered as moolasthana of pranavaha srotas.(prana vayu for poorana at all levels.)

Poorana is also assisted by sookshma guna. In biophysical viewpoint it is phenomenon of perfusion acting through membranes. Diffusion, facilitated diffusion, osmosis & active transport are four subtypes. The flexible plasma membrane defines the barrier of a cell by separating two of the body‟s major fluid compartments – the intracellular fluid within cells and the extracellular fluid (ECF) outside cells. Interestingly rate of diffusion is directly proportional to temperature (agni) & lipid solubility (sneha as a medium). Ayurveda mentions dependence of prana on agni as well as sneha.

The main aim of the cardiovascular system is to maintain the adequate tissue perfusion102 & poorana is due to prana. Thus it is Prana vayu responsible for expansion or dilatation of body channels. So long as this goes aptly, life process runs smoothly. Occlusion to this may lead to a sang pradhana samprapti process. Thus it can be observed that notion of prana is proposed for external nutrients as well as for internal vitality elements. Interestingly it is prana vayu to bring „poshak prana elements‟ upto „poshya prana elements‟.

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Entering entity: Poshaka prana

Prana Vayu

Mechanism of transport of poshya prana elements in respective srotas

Poshya ,Abhyantar Subtle Prana

Prana kala as a aushadhi kala: relevance of grasagrasantar kala103 as a aushadhi kala for prana dushti can be better understood in his above made discussion. Along with Prana Vata Dushti this kala is indicated for Vajeekaranartha(increasing vigor) & for Agni Sandeepanartha. Annapravesh (deglutition) is the function of Prana Vata. The Aushadha administered with each Grasa will come in contact with Prana Vata in Mukha (oral cavity), Kantha (throat), Urah (chest), etc., leading to the continuous contact with Prana and conditions related to that could be easily treated. Indu while commenting on same verse has precisely mentioned that sagrasa medication helps for agni sandhukshana & vajikarana whereas grasantara medication is indicated for heart diseases.104 Interestingly shukra dhatu is a pranayatana & hrudaya is main seat of prana.

Prana vayu the receptor mechanism?: Facilitation of entry of bhavapadartha/ nutrient in srotas is done by prana vayu. The receptor

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06 Discussion mechanism at different levels can again be considered as function of prana vayu only. Vd. Sathye B.v. has condemned translation of term prana as oxygen & has reported prana as not just entering entity( food, air, water) but the ability of body to receive that entity in body. In his words „alone impulse rather than anything entering by that impulse is the prana.‟105

Panchabhautikatwa of prana vayu:

Purushasookta mentions utpatti of vak from teja & Prana from from jala. This concept of utpatti of vak from teja & Prana from from jala is seen at many places in vedic & upanishadik literature. Gangadhara has echoed Vedas in his commentary on cha.chi.15 that there is utpatti of vak from teja & Prana from from jala. Some of Ayurvedic scholars have attempted to put forth dominance of one particular mahabhoota in five of its types.

Paranjape G.R. have considered panchabhutikatwa of vayu & has concluded that prana is vayu dominated whereas udana is akasha dominated. Mastishka being place of majja dhatu, prana is located at the place. However Mali in his book „panchabhautik aatmasamvad‟ has echoed vedic concepts that prana is jala dominated.

Although structurally prana is vata dominant it is able to perform its function of pranana with jala mahabhoota only.

Subtle Prana – Prana Vayu the Interdependence:

Although many of body entities are of competencies so as to be awarded status of prana, vayu is agrya (supreme) among them, quotes Charaka.106 This verse itself indicates the intimacy between subtle prana & prana vayu. Again in agrya samgraha only, Charaka considers overwork done by an individual (more than capacity of bala of own) is agrya among hetu for uparodha of prana.107 This overwork in acute condition can vitiate prana vayu & may lead to even death. However

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06 Discussion chronic overexertion will result in chronic vitiation of prana vayu and thus that of subtle prana.

Charakacharya has mentioned that marmas shall be protected. Role of maintenance of vayu at its equilibrium is very important in their (marmas) protection. Vayu is a causative factor for udeerana of pitta & kapha, & vayu is moola of prana i.e. subtle prana.108 Chakrapani has explained that avikruta vayu is foundation of jivita.109 This again implies role of vayu/ prana vayu in preservation of subtle prana resided at marma. Dhruv Anand et.al. have reported, „ Prana as the life energy and the subtle energy behind vata’.110 Bhela very clearly mentions that, Preenana of living beings i.e. subtle prana, prana is done by prana vayu.111

Thus subtle prana (resided at pranayatana & marma) is nurtured/ preserved by prana vayu. This is made possible by poorana karma of prana vayu. Prakruta Rakta dhatu is necessary for this action.

Thus ontologically prana can be equated with subtle prana. Whereas epistemologically it can be recognized by its functions; which are conducted by prana vayu.

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06 Discussion g) Hrudaya- Prana- Mahasrotas Interrelationship

Hrudaya- Prana relationship:

As reviewed previously Subtle prana resides at hrudaya. Prana vayu is responsible for dharana of hrudaya as well as dhamani. As reviewed extensively term hrudaya stands for thoracic heart as well as brain. Hrudaya is place of subtle prana, infact it is considered among three mahamarma. Dependence of vitality element of prana on „thoracic hrudaya’ is needed to be understood in context with its functions like preenana & tushti by which body tissues & mind respectively receive their nutrition. Dependence of vitality element of prana on ‘buddhi hrudaya’ can be understood owing to function that ‘buddhi hrudaya’ is the prime regulator. In fact these two cases are not contradictory. Buddhi hrudaya (nervous operations) is trying to maintain homeostasis only, allostasis in particular. For which there is need of appropriate preenana of sharira & apt tushti of manas. This appropriate preenana of sharir is possible by two mechanisms. Nutrients will be transported from hrudaya via dhamani. Also nutrients need to be received in respective srotamsi. As reviewed & discussed earlier poorana is the function of prana vayu according to Sushrutacharya. Thus apt dilatation of different body channels & receptor mechanism is again related with prana vayu as discussed earlier. In fact grammatically dhatu „pur’ (in the word poorana) stands for not only poorana but appropriate poorana.

Hrudaya is also place of manas & thus vitiation of manas leads to vitiation of prana. Manas in turn also gets vitiated by vitiation of prana. As reviewed & discussed earlier manas bhava like irshya, shoka, krodha, santap, utkantha lead to depletion in subtle prana.

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Hrudaya- Mahasrotas relationship:

Hrudaya & mahasrotas share a very close relationship. Aharrasa the extracted liquid fragment of ahara after digestion in mahasrotas gets converted in rasa dhatu at hrudaya. Functioning of heart involves role of all vayu. Samana is responsible for irana (shifting forcibly) of aharrasa into hrudaya. As discussed earlier Prana is responsible for dilatation/relaxation of chambers/valves of heart. Udana for the contraction & resultant vyana is for the vahana i.e. conduction. Conversion of aahar into aaharrasa takes place in mahasrotas. This is pachana at bulk level/ pitharapaka. Conversion in rasa dhatu is at miniature level i.e. peelu paka.

As reviewed previously amashaya is considered as synonymous with hrudaya at many places. This is why symptoms like ashraddha, aruchi, aasyavairasya, arasadnyata, hrullas are considered rasa pradoshaja

112 Also hrudaya related symptoms are seen associated with altered functioning of mahasrotas. Hrudroga is seen as part of other systemic disease & also is seen as complication of many vegavarodha & udavarta conditions which comprise mahasrotas vitiation in particular. According to sharangadhara (sha.pu.6/9) ahara rasa is brought in hrudaya from mahasrotas by samana vayu only. Thus rasa dhatu & hrudaya are physiologically associated with samana vayu residing at mahasrotas.

The close physiological relationship between rasa dhatu & mahasrotas/ agni can be understood from fact that ‘agni-nasha’ is considered as a rasa pradoshaja roga.113

This relation of agni with hrudaya is needed to be interpreted in context with vikasana & nimilana of hrudaya. Sushrutacharya has mentioned vikasana & nimilana of hrudaya in jagrut & swapat awastha.114

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Srikanthmurthy, in his commentary on Susruta has considered sankoca and vikasa as contraction and relaxation of heart respectively. He considers that the terms Jagrataha and Svapataha should be considered as the stages of life and death respectively. During one‟s lifetime, it contracts and relaxes continuously while after death it permanently stops functioning (Srikantha Murthy commentary on Su. Sha. 4/31).

However this can be explored considering relation of agni with hrudaya. As discussed earlier agni results in dilatation of all body structures & thus facilitates transport through it. Thus hrudaya during day time is vikasita. During night it is nimilata as surya is absent. Interestingly plasma volume, heart rate as well as blood pressure falls (within physiological limits) during sleep. While justifying nishedha of ratri bhojana (in grahanidosha chikitsa) Charakacharya mentions that hrudaya is mlana & ayana are samvruta (closed) during night time.115 Thus the relationship of hrudaya & mahasrotas/ agni can be understood at patho physiological levels.

As rasa dhatu is first derivative from aahar rasa, normalacy of it is closely associated with normalacy of agni. Agnimandya results in formation of aam. Its attributes like, stickiness, sliminess, heaviness, slowness, denseness, coldness lead to occlusion at minute levels. If the same phenomenon continues it may lead to occlusion at bigger levels of transport. The compromised agni, aama result in occlusive pathology. Phenomenon of occlusion if slow leads to progressive insufficiency & if acute results in spasmodic closure & results in acute insufficiency reports Vd. Nanal Vilas.116 Artheroma can be considered as aama reports Mahadevan L.117

Thus one can understand close interrelationship between hrudaya & mahasrotas/ agni.

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Mahasrotas- Prana Relationship:

Prana vayu has got function of ahara pranayana i.e. transport of food. Ahara pranayana as discussed earlier not only related with bringing bolus from mouth to stomach but it is about bringing all necessary nutrients/ elements to their target organs/ tissues. Mahasrotas is one of places of subtle prana. Guda & nabhi are enlisted in dasha pranayatana. Guda is a mamsa marma & structurally refers to the anal sphincter. Functionally guda is controlled by apana vayu. The functional equilibrium in pair of prana & apana leads to health/ maintaince of agni as reviewed previously. Purisha residing at uttarguda is said to be responsible for dharana of vayu & agni. Basti ( referred as half chikitsa )is again done via guda & pakwashaya only.

Nabhi as a pranayatana is discussed earlier. Nabhi is a place of agni & thus functionally qualifies to be mahamarma. Interdependence of prana & agni is well elaborated in veda, upanishada as well as brihtrai.

As reviewed previously gut is a very complex organization of human body. It is the only organ that contains an intrinsic nervous system that is able to mediate reflexes in complete absence of input from brain / spinal cord. The gut microbial ecosystem is even considered as largest endocrine organ in the body, proficient of producing a variety of biological compounds that, like hormones, those can be carried in the circulation and distributed to distant sites thereby influencing different biological processes. Apart from secreted juices & their role in digestion as reported in conventional physiology of gastrointestinal system, role of „gut microbiota‟ has become a new key word in contemporary scientific community. Thus agni is indeed a comprehensive conceptualization.

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Pranavaha srotas is essentially related with respiratory process. Mahasrotas itself is considered Pranavaha srotomoola. Justification is reviewed & discussed in physiological, therapeutic contexts of shwasa in earlier chapters.

Apart from respiratory process, Prana vayu is also related with nervous functions. As reviewed previously there is a close relationship between majjadhara kala & pittadhara kala. Viruddha anna results in majja dushti as aandhya is first amongst viruddhashanaja roga.118 Majja dhatu, prana vayu & rakta dhatu have got pivotal role in ayurvedic concept of nervous system. As reviewed previously gut-brain axis is been explored even in other systems of health & medicine.

Prana-Hrudaya- Mahasrotas:

Thus it can be understood that prana is term used for vayu as well element. Prana in both respiratory as well as neurological sense is seen associated with mahasrotas. Mahasrotas in turn is responsible for formation of aharrasa which is further converted in rasa dhatu & rasa- rakta are circulated by hrudaya & dhamani. Dhatu kshaya vrudhhi are essentially associated with rasa119 & rakta120. Functional status of hrudaya again in turn depends on health of mahasrotas & subtle prana & normal functioning of prana vayu.

Prana vayu, subtle prana & agni are very important physiological entities. Dhruv Anand in his observational study has reported that empowering agni & prana (vitality) was the key factor for ayurveda practitioners to use traditional Ayurvedic concepts to combat cancer.121

Thus it can be summarized that , „impulse for appropriate input (of bahya prana) & facilitating its entry is function of prana vayu whereas metabolic conversion of that element (ahara) in bodily form is function of agni. Again its circulation is to be done by hrudaya. And thus „prana-

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06 Discussion mahasrotas -hrudaya’ form an important trio in body physiology.‟ Nurtured subtle prana, aptly functioning prana vayu, Healthy mahasrotas & agni and properly functioning hrudaya lead to better health.

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2) Discussion on CHD & Observational study:

a) Discussion on CHD & prana: b) Discussion on observational study: c) Schematic chart for summury of prana & some important interrelationships: (See annexture no. V)

a) Discussion on CHD & prana:

Basic considerations of Ayurvedic pathophysiology:

Managements from western biomedicine emphasis on corrective measures on extrinsic factors like bacteria, viruses, fungi, parasites & Supplementations of intrinsic factors like hormones/ vitamins/ minerals and more biochemical entities. In contrast, Ayurveda underlines dosha, dhatu & mala as Functional & structural components. Sushrutacharya considers them as moola (root) of sharir where Dalhana has explored same in context with sambhava (genesis), sthiti (maintenance of equilibrium) & pralaya (degeneration). Ayurveda has made emphasis on both rogi & roga pareeksha. Rogi pareeksha leads to personalized approach. Whereas roga pareeksha is again not about accomplishment of some nomenclature as a disease but is about an understanding of deranged internal milieu in terms of dosha, dhatu, mala, srotas & agni. Also, Ayurveda gives more emphasis on state of mind for prevention and treatment of disease. Srotas (channels), are the structures as transporters of nutrients/biological tissue elements. Vitiation of srotasa is very

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06 Discussion important in pathogenesis of any disease. Ati pravrutti (excess activity/ secretion), sanga (all kind of occlusions), sira granthi (tumorous pathologies) & vimargagamana (displacement of biological entities in structural or functional form) are considered as basic types of vitiation of srotasa.122 The Srotas occluded or malfunctioned due to internal or external factors results in altered flow of concerned element. This leads to an accumulation of products, mostly toxic, leading to functional and even organic alterations. More deeply concept of Manovaha Srotas brings together the structural and nonstructural or physical and nonphysical Srotas. As briefed by Thakar V J, „The Ayurvedic concept of evolution of disease, based primarily in the understanding of the host-man, meaning of disease without losing sight of either the extrinsic or the intrinsic factors is comprehensive by itself.‟123

Ayurvedic interpretation of modern biomedical diagnosis is a very difficult job as Ayurveda has its own different epistemological considerations. Everytime a patient of heart disease is not necessarily that of hrudroga & vice a versa. So far as heart related ailments are considered there can be vitiation of dosha/dooshya amongst the eight basic elements Rasa, Rakta, Mamsa, Ojas, Prana vata, Vyana vata , Sadhaka pitta and Avalambaka kapha, as they maintain the integrity of the cellular structure and functions of the heart.124 Also heart disease can occur as a complication of many diseases: Anemia, infectious fever, rheumatic fever, vatarakta, diabetes, chronic respiratory disease, vomiting, bleeding disorders, worms, alcoholic intoxication, side effects of drugs, neurological disorders.125

CHD in context with Ayurved:

In the light of above discussion, we can interpret CHD in ayurvedic

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06 Discussion terms. This interpretation needs to be done at level of hetu & lakshana & srotasa & samprapti/pathogenesis. Hetu-Linga & Aushadha is a very basic methodology of interpretations of all of ayurvedic theorems in their classical ayurvedic sense.126 Hrudaya being a vital organ involving role of multiple srotasa, there is a need to interpret same in terms of srotasa as they are structural components.

CHD etiological factors (hetu) & Ayurved:

Hetu i.e. aetiological factors are given a lot importance in ayurveda because treatment/ management of a disease varies according to hetu. „Karya-karana sidhanta’ is a pivotal concept of Ayurveda & thus karana (reason) is considered to be important. Also the discontinuation of the same factor i.e. hetu is an important part of ayurvedic treatment.

Etiological factors of CHD are reviewed previously. There is a major paradigm shift in etiopathological factors of CHD. Some modern reports suggest need to rethink the role of already proven risk factors. There is an increasing trend for reversal in the socio-economic gradient for CHD (as already manifested in developed nations), with the poor and disadvantaged having equal and sometimes higher, burden of CHD and it is risk factors reports Chauhan Shradha et.al. The possible reasoning can be linked with change in the pattern of dietary habits, lack of health care facilities etc. in the lower strata.127 An article in the Internet Journal of Cardiology reports, „despite lower prevalence of such risk factors like smoking, age, sex, diabetes, hypertension etc. in Asians, incidence of CAD has been reported to be high and is constantly rising.‟128 Thus there is a need to rethink on hetu of CHD. There is a need to understand proven etiological factors in light of ayurvedic principles & present work of prana along with discussion of unique hetu in ayurvedic perspective.

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Hyperglycemia & Hypercholesterolemia: hyperglycemia & Hypercholesterolemia are considered as a risk factor for CHD. Hyperglycemia is considered as rasagata aam.129 Rasa is the first dhatu to be formed from ahara rasa & thus circulation of prana is easily gets affected by ill formed rasa dhatu. Structurally blood vessels are considered upadhatu of rakta as well as meda dhatu. Rakta is a teja pradhana whereas meda is a jala pradhana dhatu. And thus equilibrium in its structure is easily maintained. Hypercholesterolemia is again aama/ meda in rakta dhatu. Interestingly hrudaya is a common moolasthana for rasavaha as well as pranavaha srotas & hence circulation of prana gets affected with alterations in rasa-rakta. Rasa rakta gata aama is again result of diminished jatharagni, concerned dhatwagni. This agni is again dependent on prana. And thus needs to be perceived as a vitiation of „rasa-rakta, agni & prana’ as a whole.

Today scientists are in their attempts to explore concept of aama. Vaidya Ashok perceives oxidant damaged tissue debris as aama.130 Robert Svoboda has clearly stated that aama has antigenic and pro- inflammatory properties.131 Sumantran Venil & Tillu Girish have reported that, „altered gut microflora represent the only biomarker linking digestive status with inflammation. There are no established biochemical markers linking weak/abnormal digestive and metabolic status with inflammation. “Ama” may well prove to be this missing “biochemical marker.”132 Upcoming research works on aam will hopefully explore this „prana-agni’ relationship.

Alcohol/ Nicotine:

Alcohol & nicotine are proven risk factors for CHD. In ayurvedic viewpoint these are visha. All attributes of visha are opposite to that of ojus. Ojus is a pranayatana located at hrudaya which again is an important pranayatana.133 Pranaghna action of visha is because of vikasi

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06 Discussion attribute as discussed previously. This pranaghna action may be life threatening in its acute manifestation; but chronic pranaghna action will vitiate subtle prana & pranayatana in a chronic way.

Sedentary lifestyle:

Exercise is an essential part of a healthy life style. Vagbhata has quoted vyayama leads to vruddhi in agni & meda kshaya.134 Avyayama leads to shaithilya in dhatu smaghata & also diminishment in agni. Diminished agni & shithila dhatu in turn lead to vitiation/ decrease in subtle prana. Thus it can turn in vitiation of pranayatana like hrudaya.

Thus it can be noted that there is an essential mode of vitiation/diminishment of subtle prana & pranayatana (hrudaya) in pathogenesis of CHD. A clinician must diagnose each & every CHD individual for santarpanotha or apatarpanotha samprapti. Each & every individual of CHD is not necessarily a case of „Dhamani pratichaya’ or „hrudaya upalepa’ as mentioned nanatmaja vyadhi of kapha.135 Individual case may vary from santarpanotha to apatarpanotha depending on hetu, but essentially having essentially vitiation /diminution of „prana’ as in proven risk factors of CHD.

Excess salt consumption: Excess salt intake is an already proven associated with increased chd risk 136 & essential hypertension.137 Consumption of lavana rasa leads to quantative increase in rakta dhatu. Lavana also increases toxins levels & affects toxin breakdown mechanisms.138 As reviewed previously, there is a close rakta-prana relationship. Commentators have explained that prana cannot reside without rakta, whereas rakta is of no use if it does not contain prana. Thus vitiation of rakta essentially results in vitiation of subtle prana.

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Hypertension:

This is the most important risk factor for CHD. There cannot be title to title correlation of hypertension with any of ayurvedic vyadhi/ awastha. Many scholars have attempted translational research works on hypertension.139

Correlated Name of the scholars ayurvedic Concept Hypertensio Dhamani Saraswati G.N. n Prapurana Raktagata Upadhyaya Y.N. Vata Siragata Vata Chaturvedi G.N. Avritta Sharma R.K. Vataroga Vyana Bala Triguna B. Dhamani Athawale A.D. Pratichay Raktavata Sharma P.V.

It is mainly seen correlated with rakta dushti.140 Avhad Anil et.al have summarized correlations of symptoms of rakta dushti (as in cha.su.24) with symptoms of essential hypertension as shown in the chart below.141

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S. No Symptoms of Raktadushti Symptoms of EHT 1 Shirashula Headache 2 Tamodarshana Fainting / Blackouts 3 Tandra Drowsiness 4 Gurugatrata Fatigue

5 Atidaurbalya

6 Klama 7 Krodhaprachurata Anger 8 Buddhisammoha Decreased memory power 9 Mada Irritability 10 Santapa 11 Agnisada Anorexia 12 Aruchi 13 Tiktamlodgara 14 Akshiraga Retinal hemorrhage 15 Pramilaka Blurring vision

Santap, shiroruk, krodha prachurata, buddhe samoho as rakta & prana dushti lakshana resemble closely with clinical picture of hypertension.142

Unique hetu of CHD in ayurvedic perspective:

Ayurvedic pathophysiological considerations are different from conventional western biomedicine & thus there is need to discuss role of such unique hetu.

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Ojus kshaya/ Shukra kshaya: Ojus the upadhatu of shukra & essence of all seven dhatu is situated in hrudaya. Depletion in ojus is an etiological important factor so far as vikruti in hrudaya is considered. A pathophysiological interrelationship amongst manas-ojus-hrudaya-agni is already reported by some scholars.143 It is needed to be linked with prana too.

Vegavrodha: Vegavarodha is again unique consideration in ayurvedic pathophysiology. Hrudaya related symptoms in vegavarodha are reviewed previously. According to few scholars Vegavrodh causes Avritattwa & thus leads to hrudroga. 144.

Pathogenesis in CHD & Prana:

It is no doubt an injustice to correlate process of atherosclerosis with any single ayurvedic phenomenal title. ‘Dhamani Pratichaya’, ‘meda vruddhi’, ‘siragata meda’ can be possible translations. However these translations do not represent core ayurvedic interpretations of „atherosclerosis pathogenesis‟ as a whole. In this subchapter, an attempt is made to interpret it in context with subtle prana & prana vayu.

Healthy human arteries are composed of three layers: the intima, the media, and the adventitia. Endothelial cells, which form the tunica intima are in fact the physical interface between blood and surrounding tissue. Endothelium is supposed to regulate nutrient and blood components traffic. Endothelium also participates in many physiologic events, such as hemostasis, inflammation, and angiogenesis. Histologically tunica media is constituted of smooth muscle cells and extracellular matrix proteins, like elastin, collagen, proteoglycans. Atherosclerotic Plaque formation process is seen usually unfolded in a sequence of initial lesions, fatty dots / streaks, intermediate lesions,

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06 Discussion atheroma formation, distinct fibrofatty plaques and finally as complicated lesions.

As reviewed previously pathogenesis of atherosclerosis is needed to be viewed as a complex of multifactorial processes involving interplay of genetic, metabolic, environmental, behavourial, immunological, psychological, degenerative & inflammatory factors.

1} Inflammatory:

Atherosclerosis is thought to include an ongoing inflammatory process. Markers of inflammation such as interleukin-6 (IL-6) and C-reactive protein (CRP) have been associated with all-cause and cardiovascular mortality in both sexes.145 Chronic inflammation is thought to be a precursor to many diseases including cancer. As a response to inflammation and invading organisms, immune cells of the body release oxidizing agents or free radicals. To restore electrical neutrality, these radicals tear away electrons from the invading cells and in the process kill the cells. If the free radicals drift away from the site of work to new areas within the body, this could cause damage to normal cells.146 & 147 Hyperhomocysteinemia increases proneness to endothelial cell injury, resulting in inflammatory changes in the blood vessels and may lead to atherogenesis, Hyperhomocysteinemia is therefore a possible risk factor for atherosclerosis.148

Prof sathe Kalpana has reported this phenomenon of inflammation as a component of samprapti of „shotha’ along with „khara meda’ depositions. She further reports, ‘‘baahyaa siraa’ (extra cellular tissue of tunica intima and tunica adventia of blood vessel) gets vitiated by kapha (mucus, tri- glysserides, and large protein molecules), asruka ( blood leucocytes ), pitta (enzymes and anticoagulants) and vaayu (pressure); It blocks the way (baddha maarga) of circulating blood if at any other place outside the vessel inflammation of that particular organ or tissue results.

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If it is inside the vessel these dosha migrates (visarpan) the cells resulting aggregation of arterial extra cellular matrix forming Atheroma (utsedh) an inflammation of the blood vessel.’149 Inflammation comprises four sub-phenomena including swelling, heat, redness, and pain. Heat & redness are related with agni principle & rakta dushti. According to ayurveda phenomenon of pain is either related with vitiated vayu or vitiated rakta. The close relationship of rakta dhatu & prana vayu is explained previously.

2) Degenerative:

The structural changes related with atherosclerosis are considered degenerative phenomena, which primarily involve a sequence of reactions within the intima and include monocyte recruitment and macrophage formation, lipid deposition, smooth muscle cell migration, proliferation, and extracellular matrix synthesis.150 The degenerative inflammatory plaques contains lipids, activated smooth muscle cells, immune cells, foam cells, a necrotic core and calcified sites.151 Atherosclerosis is a typical age-related degenerative pathology, which is characterized by signs of cell senescence in the arterial wall including reduced cell proliferation, irreversible growth arrest and apoptosis, increased DNA damage, the presence of epigenetic modifications, shortening of telomere length and mitochondrial dysfunction. The most prominent characteristics of mitochondrial aging are their structural alterations and mitochondrial DNA damage.152

It is very important to understand this degenerative component of CHD pathogenesis. Although the artheoma/plaque is a structure that is capable of making avarodha in srotas/sira, it shall not necessarily be considered „santarpanotha’ phenomenon every time. Degeneration at cellular levels is because of vitiation/ depletion of apara ojus/ apara shukra. Both of them are sites of subtle prana. According to Sushruta

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06 Discussion depletion & increase in all dhatu are because of with rakta, which again is a pranayatana.

3} Immunologic:

It is by now well established that atherosclerosis is accompanied by adaptive immune responses and that the early phase of the disease is dominated by immune cells, particularly macrophages. In atherosclerosis pathology, monocytes and macrophages play the most important role by accumulating LDL particles in their oxidized form and producing proinflammatory cytokines. Atherosclerotic plaque macrophages reveal distinct phenotypes that are distinguished into M1 (proinflammatory) and M2 (anti-inflammatory) macrophages. Numerous environmental signals (cytokines, microbial cell molecules) that are received by macrophages drive their polarization, but it must be determined whether this classification reflects different macrophage subtypes or plasticity and phenotypic tissue changes, but the balance between subsets is crucial. M1 macrophages are dominant in symptomatic atherosclerotic plaques, while M2 macrophages are more frequent in asymptomatic plaques. Nevertheless, a positive correlation of both M1 and M2 macrophages with atherosclerotic lesion severity was also observed.153

Interestingly HIV patients, who lack CD4+ T cells (and particularly Th1 activity), develop aggressive cardiovascular disease, particularly when modern highly active antiretroviral treatment has been used to prevent rapid development of AIDS.154 This immunologic component of atherosclerosis pathogenesis is again relevant in context with prana as prana itself is denotation of a vitality element. Bala is the ayurvedic concept of immunity.155 According to Sushruta, Ojus (a pranayatana) situated at hrudaya (pranayatana) is considered equivalent with bala. And thus degenerative mode of

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06 Discussion pathogenesis of CHD is essentially reflects part & parcel of vitiation of prana.

4) Metabolic:

Metabolic syndrome is an important risk factor for cardiovascular disease incidence and mortality, as well as all-cause mortality.156 There are some controversies in definition of metabolic syndrome. Historically, Reaven was the first to put forward the concept of 'syndrome X', (later renamed as Metabolic Syndrome), hypothesizing that it was a central feature in the development of CHD and DMT2, mainly through target tissue resistance to insulin action.157 In 1998, WHO proposed a definition by the presence of IR or its surrogates, impaired glucose tolerance (IGT) or DMT2, as essential components of the syndrome, along with at least two of the following parameters: raised BP, hypertriglyceridemia and/or low HDL-cholesterol, obesity (as measured by waist/hip ratio or body mass index (BMI)), and microalbuminuria.158 Later the microalbuminuria was hyperinsulinemia was proposed in definition.159 In addition, waist circumference and not BMI was regarded as the main indicator to assess obesity, while introducing different cut-offs from those previously used for the other components of the syndrome.160 In 2005, the International Diabetes Federation (IDF) published newer criteria „abdominal obesity‟ as a prerequisite of the diagnosis of MetS, with particular emphasis on waist measurement as a simple screening tool.161

Scholars have reported that, fully developed metabolic syndrome without complications can be compared with Apathyanimittaja prameha and complicated stage of metabolic syndrome can be compared with Updrava of Avaran162 & with concept of sthaulya.163

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06 Discussion

The component of metabolic syndrome comes under medovaha srotodushti, prameha, raktavaha srotodushti. Vrukka & vapavaha are moolasthana of medovaha srotas. Sneha is most important causative factor for agni to work and thus medovaha srotomoola are closely associated with agni. Vrukka being closely associated with agni is able to perform its function of sara-kitta vibhajana of jaliya ansha. Thus metabolic syndrome can be interpreted as deranged triangle of meda & agni & rakta.

This derangement of meda-agni-rakta triangle essentially related with vitiation of subtle prana as alpa pranata is a symptom in medoroga as reviewed previously.

5) Psychological:

Role of psychological causes in CHD is well established. Stress164, Depression165 anxiety166 & 167 burn out168 are proven to be associated with CHD. Hrudaya being place for manas & ojus gets vitiated by manas factors.

However there is an important component of prana vitiation in same context. Hrudaya is place for subtle prana as well as prana vayu is responsible for dharana of hrudaya & indriya. As reviewed previously, „Prana kshaya karaka’ kshayaja yakshama is caused by manas factors like irshya, bhaya, shoka, utkantha, krodha. These manas bhava lead to depletion of subtle prana.

Thus it can be concluded that dosha/dooshya involved in CHD pathogenesis are related with subtle prana/prana vayu. It can be summurised in a table as given below.

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Components in Dosha/ Dooshya Is it site of subtle CHD involved Prana/ Prana vayu Pathogenesis Inflammation Rakta, sira  vata pradhana tridosha  Aama & impaired agni  Degeneration Rasa  Rakta  Shukra  ojus  Immunologic Rakta,  ojus  Metabolic Agni  Psychological Manas prerena by prana  Ojus  Rasa (Tushti) 

Some more remarks on Prana & CHD Pathogenesis:

Apart from this ayurvedic interpretations of hetu & pathogenesis of CHD, there is need to be understood CHD in context with few core ayurvedic conepts.

CHD is usually seen interpreted only in the light of cholesterol deposits in vascular fabric. Thus some gugglu kapla & other lekhana dravya proven in hypercholestromia are proposed to use in same. However one must understand that plaque formation is just a part of pathogenesis of CHD where prognosis is determined by many other factors. Arterial stiffness results from a degenerative process affecting mainly the

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06 Discussion extracellular matrix of elastic arteries under the effect of aging and risk factors.169 As reviewed previously traditional angiography provides only estimates of the severity of most lesions; ischemia may result from dynamic obstruction superimposed on fixed stenoses, and lesions can progress surprisingly rapidly, heralding a poor prognosis 170 & interestingly a substantial burden of atherosclerosis can exist without producing stenosis.171 Also relevance of animal models is again questionable. The molecular and cellular mechanisms underlying the disease cascade have been thoroughly investigated in experimental animals and cell culture, but the question of how these models can correctly mimic the human course of the disease remains open to debate.172

And thus this is needed to be viewed in a different manner. It can be better perceived as inadequacy of poorana by prana which is following rakta. Structurally this adequacy is result of narrowing of lumen due to obstruction by plaque formation. This atherosclerotic plaque is not necessarily everytime to be considered as santarpanotha phenomenon but needs to be viewed as vitiation of prana as prana is the force for filling a srotas. This is needed to be viewed as vikruti of subtle prana/ prana vayu. As rasa dhatu is first derivative from aahar rasa, normalcy of it is closely associated with normalcy of agni. Agnimandya results in formation of aam. Concept of aam is certainly a unique contribution to etiopathology of intrinsic diseases. Its attributes like, stickiness, sliminess, heaviness, slowness, denseness, coldness lead to occlusion at minute levels. If the same phenomenon continues it may lead to occlusion at bigger levels of transport. The compromised agni, aama result in occlusion, phenomenon of occlusion if slow leads to progressive insufficiency if acute results in spasmodic closure of of inutrient supply causing insufficiency reports Vd. Nanal Vilas.173 Artheroma is aama reports Mahadevan L.174

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06 Discussion

Term Ayuh itself is means, „one that goes on continuously.‟ Gati & Gandhana both are meanings of root word „va’, again implies the meaning, „being in motion‟. This maintenance of ayuh is a kind of gati. Vikruti in prakruta gati of body elements is considered under phenomenon of udavarta. Association of vegavarodha in hrudaya related symptoms is reviewed previously. According to Sushrutacharya phenomenon of Udavarta vitiates vata, mootravaha, purishavaha, raktavaha, kapha and medovaha srotas in particular.175 Mention of raktavaha & medovaha srotas in pathogenesis of udavarta is very important. Sira is upadhatu of rakta & meda & hence is an obvious site for vitiations derived from udavarta.

Apart from udavarta there is one more important phenomenon. Rasa dhatu (which itself is a sthana of pitta dosha) of optimum quality is made from well digested ahara. According to sharangadhara samhita, transport of rasa dhatu from mahasrotas to hrudaya is function of samana vayu.

CHD Inadequacy in poorana Poorana the function of prana vayu Udavarta Vitiation of anuloma gati of prana Deranged rasa dhatu Prana-samana-Agni due to impaired agni vitiation

Vd Gadgil D P has reported that „….The vata dosha thus imbalanced is responsible for producing heart diseases. But unfortunately once the atherosclerosis was known, it was cholesterol & fat content of diet that was blamed heavily as causative factor. Even today things have not

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06 Discussion changed much. The market is flooded with fat free eatables to reduce body cholesterol……‟176

Thus instead of giving importance to structure called as an atherosclerotic plaque; pathogenesis in CHD can be interpreted in functional manner as attempted in this subchapter. Corrective measures organized for correction of vitiation of subtle prana, normalising prana vayu, Rakta prasadana, empowering oja / shukra & protecting trimarma can result in better clinical outcomes.

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06 Discussion b) Discussion on observational study:

Nadi:

Vata-kapha nadi is seen in maximum participants. In a previous study mahale namita & others have observed a strong association of CHD with vata-kapha prakruti.177 The atherosclerotic phenomenon is a kind of grathana only. It means to fasten, to thicken or to be clogged. Sira granthi can be interpreted as deformities in wall of channel leading further to accumulation178 The pathogenesis of „Granthi’ is associated with vata-kapha reports Vabhatacharya while describing shukra dushti.179 Jivha: Amongst 150 participants 62% were having saama jivha whereas 38% participants exhibited nirama jivha. Aama is seen associated with CHD. Rasa being the first dhatu generated from aharrasa, is easily affected by vitiation of agni/mahasrotas

Mootra:

Amongst 150 participants 36 participants (24 %) reported bahumootrata i.e. frequent urination. However (77.7 % of them ) were pramehi. In rest of participants bahoomootrata can be interpreted as sign of samata.

Mala:

60% participants reported constipation. Detailed analysis of purishavaha srotas is mentioned in same chapter.

Annavaha srotas:

Ati matrasya bhojana, akale bhojana & ahitasya bhojana are dushti hetu of annavaha srotas. All of three are showing a positive association in observational study carried amongst CHD participants.

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06 Discussion

Excess quantity of bhojana is a dushti hetu of annavaha srotas & purishavaha srotas as well as a dushti hetu for prana vayu. Ahara pranayana is karma of prana & thus gets vitiated by excess of ahara.180 Excess intake of food is also considered as agrya hetu of aama.181

Akale bhojana is dushti hetu of annavaha srotas as well as a dushti hetu for samana vayu.182 Timely bhojana is considered as agrya hetu for aarogya.183 The homeostatic mechanism of tridosha is regulated in context with kala i.e. time. Samana vayu & agni both get vitiated with an untimely lunches. Thus akale bhojana not only vitiates samana vayu & annavaha srotas but also interrupts dosha gati which is maintained by timely ahara.

Ahita food items not only vitiate annavaha srotas but also vitiate aharrasa & rasa dhatu inturn.

Purishavaha srotas:

Purishavegavidharana, atyashana, ajeernadhyashana, doorbalagni & krushtwa are causative factors of vitiation of purishavaha srotas. Except krushtwa all other factors were seen associated positively.

Purishavega vidharana leads to udavarta. Role of udavarta in CHD pathogenesis is discussed earlier. Vegadharana is considered as agrya factor for non-health.184 Some studies have reported vitiation of neurohumors due to vega dharana.185

Ajeernadhyashana shows positive association. Ingestion of food before completion of digestion of previously taken one is an agrya factor for vitiating grahani186 as well as purishavaha srotas.

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06 Discussion

Doorbalagni which is also showing a positive association refers to incompetency of agni to digest food. Both ajeernadhyahana & doorbalagni result in formation of rasa dhatu of deranged quality.

Krushatwa refers to less upachaya. As discussed previously agni is dependent on snigdhatwa and thus on dhatu. However in present study krushtwa is not seen associated with CHD.

Agni dushti hetu:

Agni dushti hetu like Abhojana, Vishamashana, Asatmya bhojana, Guru bhojana, Sheet bhojana, Ati rooksha bhojana, Sandushta bhojana, shodhana vibhrama, Vyadhi karshana, Vega vidharana were assessed.

Abhojana is a hetu for pranakshaya dushti in direct manner as reviewed previously. It is also related to depletion in rasa dhatu. Anna is said agrya in elements those shall be never skipped.187 Anashana is considered as agrya factor for depletion in life span.188 In present study in total 55% participants had this hetu rarely or once in a week. But at the same time 20% participants had this hetu as almost daily.

History of vishamashana was found significantly. Vishamashana is considered as agrya factor for agni dushti.189

Asatmya bhojana too is an important dushti hetu for agni however it was not found significantly.

Guru bhojana was found significantly. It is considered as agrya hetu for making disturbance in process of vipaka i.e. final stage of digestion.190

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06 Discussion

Thus it directly alters composition of rasa dhatu, making it more guru with deranged vipaka.

Sheeta bhojana is again agni dushti hetu., Atee rooksha bhojana was found significantly. As reviewed previously, sneha is the very basic prerequisite for functioning of agni.

Sandushta bhojana too is an important dushti hetu for agni however it was not significantly only in rare or once in a week frequency.

Shodhana vibhrama too is an important dushti hetu for agni however it was not found significantly.

Vega vidharana was found significantly in frequencies like Rare , 1/7 days , 2-3/ 7 days. Vega vidharana leads to udavarta & results in agnidushti.

Annavaha srotodushti lakshana: Annanabhilasha, Aruchi, Avipak, Chhardi are dushti hetu of annavaha srotas. All of them except chhardi are showing a positive association in observational study carried amongst CHD participants.

Annanabhilasha & Aruchi which are seen positively associated in agni dushti in CHD cases, are also symptoms of rasa dushti.

Avipaka as a symptom of agni dushti was seen in many participants more frequently.

Chhardi was found rarely or in frequency of once in a week.

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Purishavaha srotodushti lakshana:

Krucchra Purisha, Alpalpa Purisha, Sashabda Purisha, Sashoola Purisha, Atee Drava Purisha, Atee Grathita Purisha, Atee Bahu Purisha were assessed.

Krucchra Purisha was reported more in rarely & 2-3 per week frequency. Kruchrata in purisha pravartana denotes loss of purisha sneha which is mala of majja dhatu. Majja is a quality sneha working at level of manas & buddhi. Vata vruddhi & depletion of sneha is at purishavaha srotas result in krucchra purisha.

Alpalpa Purisha is seen in 58% participants. It denotes excess shoshana. Vitshosha is seen as symptom of vataja pandu thereby implies rasa dushsti again.

Sashabda purisha was found more in rare or 2-3 days per week frequencies. This is because of vata pradhana dushti in purishavaha srotas.

Sashoola purisha was found more in rare or 3-4 days per week frequencies. Shoola again denote dominance of vata/ rakta dushti.

Atee grathita purisha was found more in more frequencies. Role of vata dushti & udavarta is explained earlier.

Atee drava purisha was mostly found in rare cases. Thus it can be remarked that drava guna pradhana dushti of grahani / pakwashaya is not associated herewith.

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06 Discussion

Atee Bahu Purisha i.e. relatively more volumes of purisha were not found significantly.

Some more important lakshana:

Aasyavairasya, Amlak, Urodaha, Udar daha, aadhman, aatop, aanah, vishtambha, Gala vidaha were assessed.

Aasyavairasya was found significantly. It denotes vitiation of rasa dhatu. Amlaka was not found significantly. As reported earlier Atee drava purisha was also not significant. Thus it can be remarked that drava guna pradhana vikruti in mahasrotas is not associated with CHD.

Urodaha, Udar daha & Gala vidaha are not seen associated with CHD participants. Thus it can be remarked that ushna guna pradhana vikruti in mahasrotas is not associated with CHD. In earlier studies scholars have reported association of CHD with kapha & vata-kapha prakruti.

Aadhman is seen related positively. Genesis of vayu is as a mala of anna during third awasthapaka of ingested food. Altered metabolism in pakwashaya results in same. Aatop i.e. gud-gud sound was seen positive in half of participants. It denotes agni dushti. Aanah i.e. tension in abdomen & constipation was reported by less than half of participants & thus was not seen related. Vishtambha i.e constipation as well as obstruction in passing of flatus was reported by 60% participants. This vishtambha is part & parcel of udavarta.

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06 Discussion

Pranavaha srotas Hetu Irshya, Utkantha, Bhaya, Shoka, krodha, anashana, Ati maithuna, sandharana, raukshya, Kshudhitasya vyayama, Daruna karma were assessed.

Irshya: most number of participants have reported irsha of grade3 and secondly to that of grade2. This leads to subtle prana vitiation.

Utkantha: most number of participants have not reported utkantha and second largest number of participants show utkantha of grade 1. Thus utkantha do not show a positive relationship.

Bhaya: Most number of participants have reported Bhaya of grade 4 and secondly to that of grade 3. This leads to subtle prana vitiation. Bhaya also leads to vitiation of swedavaha srotas & ambuvaha srotas. Shoka: most number of participants have reported Shoka of grade 3 and secondly to that of grade 1. This leads to subtle prana vitiation. Shoka also leads to vitiation of swedavaha srotas Krodha: most number of participants have reported Krodha of grade 2 and secondly to that of grade 3. This is associated with vitiation of sadhaka pitta.

Anashana is discussed earlier as agni dushti hetu.

Ati maithuna: It is seen associated with CHD. It results in shukra kshaya & thus in ojus kshaya. Both of them are pranayatana.

Sandharana: was found more in 2-3 days per week & once in a week frequencies.

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06 Discussion

Raukshya: Raukshya is seen positively associated with CHD. Snigdha is first & foremost guna so far as nature & nourishment of subtle prana is considered & is discussed well in a subchapter during discussion of conceptual work.

Kshudhitasya vyayama: was not found significantly associated.

Daruna karma: Daruna karma is seen positively associated with CHD. This extensive exertion leads to shrama & thus results in vata vruddhi.

Rasa vaha srotas dushti hetu

Guru bhojana, Sheeta bhojana, Ati snigdham, Ati matram, Chintyanam Ati chintana were assessed.

Guru bhojana & Sheeta bhojana and their concurrent effects are discussed earlier as hetu of agni dushti. Ati matram bhojana is too discussed earlier as dushti hetu of annavaha srotas.

Ati snigdham: Ati snigdha ahara is seen associated positively. It leads to rasa dushti with guru & snigdha guna. It also vitiates medovaha srotas & sira in turn.

Chintyanam Ati chintana: It is seen associated positively as almost 70% participants report habitual overthinking on particular issues to a troubling extent. It vitiates rasadhatu as manas is situated at hrudaya.

Summury: Hetu of Annavaha srotodushti & rasavaha srotodushti are seen 100% associated. Annavaha srotas is mainly place of kapha & pitta. Amashaya

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& kledaka kapha is responsible for nutrition of kapha at rest of sites of kapha. Thus vitiation hetu of amashaya are seen associated with that of CHD. Hrudaya being moolasthana of rasavaha srotas

They are followed by dushti hetu of purishavaha & pranavaha srotas. Agni dushti hetu are at last to be seen associated.

Annavaha dushti lakshana & Purishavaha dushti lakshana are seen associated with CHD, Purishavaha srotas dushti lakshana are also seen associated.

Thus null hypothesis is rejected & there is significant association amongst dushti hetu & lakshana of agni, prana with CHD. Thus pathophysiological interrelationship of hrudaya, mahasrotas & prana is explored.

Ho: There is no significant correlation between hrudaya, mahasrotas & prana. Ho: There is significant correlation between hrudaya, mahasrotas & prana.

Limitations: The study was an observational study. In an interview of a participant we need to rely on answer from participant. Experimental study based on similar hypothesis can generate more better outcomes.

Scope for further studies: a) Chi, the equivalent of prana in Traditional Chinese Medicine (TCM) is claimed to be measured through instruments and its loss has been observed at the time of death. Electrons have also come under study recently in health of individuals. Here, we have a complex and yet unexplored area of subtle energies that impacts

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health and may be useful in defining death.191 Interdisciplinary major projects may come up for Measurement of subtle prana. b) Prana residing at different pranayatana & its uniqueness & aushidhi with particular gamitwa can be studied. c) Pranakamiya rasayana the title of one of paada of rasayana adhyaya implies herbs those can give nutrition of subtle prana. With similar hypothesis clinical studies can be performed.

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8 Bernstein Defining Life: Products or Processes? Robert Root-Bernstein Journal of Biomolecular Structure &Dynamics, ISSN 0739-1102Volume 29, Issue Number 4, February 2012

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06 Discussion

9 R. M. Hazen et al., American Mineralogist, Volume 93, pages 1693–1720, 2008

10 Szostak J. Attempts to Define Life Do Not Help to Understand the Origin of Life Journal of Biomolecular Structure &Dynamics, ISSN 0739-1102Volume 29, Issue Number 4, February 2012

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23 P.J. Rosch & M.S. Markov (eds.). Bioelectromag-netic Medicine, pp. 541– 562. Marcel Dekker, Inc., New York, NY.

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25 Chakrapani: , ; ||

26 Cha. Su.1/28

27 Su. Su.41/12

28 Su. Chi.31/1

29 Su. Su. 46/516

30 Cha. Chi. 15/201

31 Cha. Chi. 28/82

32

Cha. Vi. 5/ 14

33 Cha. Chi 23/26

34 ; Chakrapani on Cha. Chi.23/26

35 | | || Ashtang Samgraha: su.1/28

36 || Su. Su. 46/523

37 Dalhana on Su. Su. /523

38

39 Su.su. 46/515

40 Dalhana on Su.Su. 46/515

41 Su.Su. 46/522

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42 Nanal Vilas, Insights into ayurved, Page 173, Nanal softwares & publishers, Pune

43 Su. Su. 17:13

44 - , Dalhana on Su. Su. 17:13 45 Ah. sha 3/55

46 Cha.Chi. 15/6

47 Cha. su. 27/342

48 Chakrapani on Cha. su. 27/342

49 ४० Dalhana on. Su. Ka. 4/40

50 पꅍचमे अस्थिꅍय अनुप्रवि�यति प्राणम अस्ननम च दशु यति, िेन पिवभेदो, हि啍का दाि�च भिति I Su. Ka. 4/39

51 | | ||२८|| Ah. San. sharir 5/28

52 Mac Cord et.al. the biology & pathology of oxygen radicals, Annals of medicine 89(1978)- 122.

53 Patwardhan Kishor, The history of the discovery of blood circulation: unrecognized contributions of Ayurveda masters, Advances in Physiology Education 36: 77– 82, (2012)

54 Cha.Su. 24/44

55 Su. Su. 14/21

56 Ah. Ni.6/25

57 Cha. Su. 24/14

58 MK Taneja Nitric oxide Bhramari Pranayam and deafness Indian journal of otology Year : 2016 Volume : 22 Issue : 1 Page : 1-3

255

06 Discussion

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68 Nagendra H R The power of prana The power of prana. Int J Yoga 2009;2:45

69 TM Srinivasan Bridging the mind-body divide Int J Yoga. 2013 Jul-Dec; 6(2): 85–86. 70 Swatmarama. commentary by Swami Muktibodhananda, Hatha Yoga Pradipika, Munger, India: Yoga Publications Trust; 1998; 3rd ed, 150.

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502

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73 Brown R, Gerbag P. Sudarshan Kriya yogic beathing in the treatment of stress, anxiety and depression. J Altern Complement Med 2005;4:711-7.

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76 Pragati Oswal, Raghuram Nagarathna, John Ebnezar, and Hongasandra Ramarao Nagendra. The Journal of Alternative and Complementary Medicine. March 2011, 17(3): 253-258.

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80 Ramraya Sangavadekar (Editor), Shree Dnyaneshwari, Chapter 6 page 135- 139, Shree Sadguru Vishwanath Maharaj Rukdikar Trust, Kolhapur.

81 Ramraya Sangavadekar (Editor), Shree Dnyaneshwari, Chapter 6 page 139, Shree Sadguru Vishwanath Maharaj Rukdikar Trust, Kolhapur

82 Thadani N.V. The mystery of Mahabharata The explanation of Epic Part I 1934 (223& 224)Bharat publishing house Karachi.

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257

06 Discussion

87 Ravitz, L.J. 1982. History, measurement, and appli-cability of periodic changes in the electromagnetic field in health and disease. Ann. N. Y. Acad. Sci. 98: 1144–1201

88 Cha. Su.30

89 Kenneth G. Zysk The science of respiration & doctrine of bodily wind in ancient india. Journal of the American oriental society vol 113, no. 2 (apr-june 1993 page 198-213)

90 HW Bodewitz ; „Kingship of Prana‟ ; Ritual, State, and History in South Asia: Essays in Honour of J.C. Heesterman

91 Cha. Chi. 28/3

92

३ Chakrapani on cha. Chi. 28/3

93 Mahesh TS, Shreevidya M. A review on balya action mentioned in Ayurveda. Journal of Ayurveda Integr Med 2014;5:80-4

94 Su.su. 15/3

95 , ; Dalhana on su.su. 15/3

96 Monneire Williams, (1899 1st ed.). (Reprint 1995), A Sanskrit English Dictionary by Motilal Banarasidas Publishers Pvt. Limited, Delhi, page:642

97 Apate page 133, geervana laghu kosha 98 Nanal Vilas Madhujeevan (quarterly) Shwasa visheshanka, Madhavi prakashana, mahim Mumbai.

99 Nanal Vilas: Insights into Ayurved: Page 69, Nanal softwares & publications, sadashiv peth pune.

100 Nanal Ramesh Madhujeevan (quarterly) Purisha visheshanka Madhavi prakashana, mahim Mumbai.

101 Nanal Vilas Insights into Ayurveda page 70 Nanal softwares & publications,sadashiv peth, Pune.

102 Mike Macintosh and Tracey Moore, Caring the seriously ill patient, Second Edition, Taylor and Francis group, Chapter 1. p. 21.

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06 Discussion

103 Ah.su. 13/39

104 - Indu on Ashtang Sang. Su. 23/22

105 Vd. Sathye B.v. , Praveshkarta: pravishta padarth nahi, Page 7, Madhujeevan pranavaha srotas visheshank, feb 2010, Madhavi prakashana Mahim, Mumbai

106 Cha.su.25

107 Cha.Su.25/40

108 Cha.si.9/7

109 Chakrapani on Cha. Si. 9/7

110 Dhruv Anand et. al. The journal of alternative and complementary medicine Volume 20, Number 5, 2014, pp. 364–370

111 :| . Mishra, Y.C. (2011.)., Ayurvediya Kriya sharir, Chaukhamba Publications New Delhi ISBN 978-81-89798-07-9 page no. 135

112

113 ………………Cha. Su. 28 / 10

114 Su. Sha 4/ 31,32

115 cha. Chi. 15/241

116 Late Vd. Nanal Vilas, Cardiotonic Herbs. Nanal softwares & Publications

117 Mahadevan L. Ayurvedic Clinical Practise Vol I, page 142,Sri sarada Ayurveda Hospital, Derisanamcope.

118 Cha. Su. 27/102

119 Su.su. 15/32

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06 Discussion

120 Su.su. 14/21

121 Dhruv Anand et.al. The journal of alternative and complementary medicineVolume 20, Number 5, 2014, pp. 364–370

122 Cha. Vi.5/24

123 Ancient Science of Life, Vol. I, No.1, July1981, pages 13-19 Evolution of diseases i.e. samprapti vignana V. J. Thakar.

124 Mahalle NP, Association of constitutional type of Ayurveda with cardiovascular risk factors, infl ammatory markers and insulin resistance.Journal of Ayurveda & Integrative Medicine | July-September 2012 | Vol 3 | Issue 3

125 Athawale VB. Cardiology in Ayurveda. Printed at Akshar Pratiroop Pvt. Ltd.: Mumbai; 1979. p. 1-175.

126 Cha. Su. 1/24

127 Shraddha Chauhan, Dr. Bani Tamber Aeri, Prevalence of cardiovascular disease in India and it is economic impact- A review International Journal of Scientific and Research Publications, Volume 3, Issue 10, October 2013 , ISSN 2250-3153)

128 Enas E.A., Senthilkumar A., Coronary Artery Disease in Asian Indians: An Update and Review. The Internet Journal of Cardiology, 1 (2), (2001).

129 Mahadevan L. Ayurvedic Clinical Practise Vol I, page, Sri sarada Ayurveda Hospital, Derisanamcope.

130 Ashok D.B. Vaidya Metabolic management: The role of nutraceuticals, nutritionals and naturals Editorial Year : 2014 ,Volume : 1 , Issue : 2 , Page : 79-82

131 Svoboda RE. Ayurveda Life Health and Longevity. Penguin Books India; 1992.

132 Venil N. Sumantran & Girish Tillu Cancer, Inflammation, and Insights from Ayurveda Evidence-Based Complementary and Alternative Medicine Volume 2012 (2012), Article ID 306346, 11 pages

133

Cha. Chi. 24/30-31

260

06 Discussion

134

135 Cha.su. 20/17

136 P Strazzull et.al. Salt intake, stroke, and cardiovascular disease: meta- analysis of prospective studies BMJ 2009; 339 doi: http://dx.doi.org/10.1136/bmj.b4567 (Published 25 November 2009)Cite this as: BMJ 2009;339:b4567

137 Lewis K. Dahl, M.D Possible role of chronic excess salt consumption in the pathogenesis of essential hypertension The American Journal of Cardiology Volume 8, Issue 4, October 1961, Pages 571-575

138 Cha. Su. 26 139 Ramesh Bhayal et.al, Role of Virechana Karma and Shaman Chikitsa in the management of Uccharaktachapa (EHT), MD thesis, GAU, Jamnagar, 2003.

140 Dr. Rathod M. Understanding of hypertension in ayurveda International Ayurvedic Medical journal Volume 1; Issue 1; Jan – Feb 2013

141 Avhad Anil Understanding Essential Hypertension through Ayurveda – A Review International Journal of Pharmaceutical & Biological Archives 2013; 4(4): 591 - 595

142 Cha. Su. 24

143 Prakash Mangalasseri The role of biological fire (agni), innate psychic strength (satwa) and vital essence (ojus) in manifestation of depressive disorder JAHM vol 2, Issue 7

144 Marathe Amruta Review of hridroga with special reference to veg-vidharan hetu IAMJ Volume 4; Issue 09; September- 2016

145 Pai JK, Pischon T, Ma J et al (2004) Inflammatory markers and the risk of coronary heart disease in men and women. N Eng J Med 351:2599–2610

146 Oschman JL. Chronic disease: Are we missing something? J Altern Complement Med. 2011;17:283–5.

147 Oschman JL. Can electrons act as antioxidants. A review and commentary? J Altern Complement Med.2007;13:955–67.

148 Christen WG, Ajani UA, Glynn RJ et al (2000) Blood levels of homocysteine and increased risks of cardiovascular disease: causal or casual? Arch Intern Med 160:422–434

261

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149 Sathe kalpana, vascular biology in ayurved, Dhanwantari (quarterly) February 2008, Pune

150 S. Karger AG 2014, Immunological Aspects of Atherosclerosis PHYSIOLOGICAL RESEARCH Volume: 63 Pages: S335-S342 Supplement: 3

151 Sobenin 2015 Mitochondrial Aging: Focus on Mitochondrial DNA Damage in Atherosclerosis - A Mini-Review GERONTOLOGY Volume: 61 Issue: 4 Pages: 343-349

152 Sobenin 2015 Mitochondrial Aging: Focus on Mitochondrial DNA Damage in Atherosclerosis - A Mini-Review GERONTOLOGY Volume: 61 Issue: 4 Pages: 343-349

153 Sobenin 2015 Mitochondrial Aging: Focus on Mitochondrial DNA Damage in Atherosclerosis - A Mini-Review GERONTOLOGY Volume: 61 Issue: 4 Pages: 343-349

154 Paton P, Tabib A, Loire R, Tete R. Coronary artery lesions and human immunodeficiency virus infection. Res Virol. 1993; 144: 225–231. & Lewis W, Grupp IL, Grupp G, Hoit B, Morris R, Samarel AM, Bruggeman L, Klotman P. Cardiac dysfunction occurs in the HIV-1 transgenic mouse treated with zidovudine. Lab Invest. 2000; 80: 187–197.)

155 Byadgi P.S. Concept of immunity in Ayurveda Journal of Applied Pharmaceutical Science 01 (05); 2011: 21-24

156 Galassi A Metabolic syndrome and risk of cardiovascular disease: a meta- analysis American Journal Med. 2006 Oct;119(10):812-9.

157 Reaven GM: Banting lecture 1988. Role of insulin resistance in human disease. Diabetes. 1988, 37: 1595-1607.

158 Alberti KG, Zimmet PZ: Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: diagnosis and classification of diabetes mellitus provisional report of a WHO consultation. Diabet Med. 1998,

159 Balkau B, Charles MA: Comment on the provisional report from the WHO consultation. European Group for the Study of Insulin Resistance (EGIR). Diabet Med. 1999, 16: 442-443.

160 Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA. 2001, 285: 2486-2497.

161 Grundy SM, Brewer HB, Cleeman JI, Smith SC, Lenfant C: Definition of metabolic syndrome: report of the National Heart, Lung, and Blood

262

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Institute/American Heart Association conference on scientific issues related to definition. Arterioscler Thromb Vasc Biol. 2004, 24: e13-e18

162 Bharat C Padhar Concept of metabolic syndrome in Ayurveda Journal of Medical Pharmaceutical and Allied Sciences (September_2016); 188-197

163 Antiwal Meera Metabolic syndrome in ayurveda – a critical review IAMJ: Volume 1; Issue 4; July – Aug 2013

164 Stephen J Bunker, et.al. "Stress" and coronary heart disease: psychosocial risk factors Med J Aust 2003; 178 (6): 272-276.

165 Reiner Rugulies, Depression as a predictor for coronary heart disease: a review and meta-analysis American Journal of Preventive Medicine Volume 23, Issue 1, July 2002, Pages 51–61

166 I Kawachi Symptoms of anxiety and risk of coronary heart disease. The Normative Aging Study. Behavioural medicine November 1, 1994, Volume 90, Issue 5 167 Annelieke M. Roest, Anxiety and Risk of Incident Coronary Heart Disease : A Meta-Analysis Journal of the American College of CardiologyVolume 56, Issue 1, 29 June 2010, Pages 38–46 168 A Appels Burnout as a risk factor for coronary heart diseases, Behavioral Medicine, 17, issue-2, 1991. 169 Palombo, C ; Kozakova, M (Kozakova, Michaela) Arterial stiffness, atherosclerosis and cardiovascular risk: Pathophysiologic mechanisms and emerging clinical indications, Vascular pharmacologyVolume: 77 Pages: 1-7

170 Moise A, Theroux P, Taeymans Y, Waters DD, Lesperance J, Fines P, Descoings B, Robert P. Clinical and angiographic factors associated with progression of coronary artery disease. J Am Coll Cardiol. 1984; 3: 659–667 171 Arnett EN, Isner JM, Redwood DR, Kent KM, Baker WP, Ackerstein H, Roberts WC. Coronary artery narrowing in coronary heart disease: comparison of cineangiographic and necropsy findings. Ann Intern Med. 1979; 91: 350–356

172 Perrotta, Ultrastructural Features of Human Atherosclerosis Ultrastructural pathology, Volume: 37, Issue: 1, Pages: 43-51 (2013) 173 Late Vd. Nanal Vilas, Page 45,Cardiotonic Herbs. Nanal softwares & Publications

174 Mahadevan L. Ayurvedic Clinical Practise Vol I, Sri sarada Ayurveda Hospital, Derisanamcope

175 | ||३८|| Su. Uttar. 55/38

263

06 Discussion

176 Vd Gadgil D P , Heart disease & cancer in Ayurveda , Manakarnika Publications, Pune

177 Mahalle NP, Kulkarni MV, Pendse NM, Naik SS. Association of constitutional type of Ayurveda with cardiovascular risk factors, infl ammatory markers and insulin resistance. J Ayurveda Integr Med 2012;3:150-7.

178 . A. Patankar Concept of Pratiloma Vata and practical utility of Anulomana principle in its management –MD dissertation - 1991, IPGTRA Jamnagar.

179 Ah. Sha.1/11

180 Ah. Ni. 16/19

181 Cha. Su. 25/40

182 Ah. Ni. 16/26

183 Cha. Su. 25/40

184 Cha. Su. 25/40

185 Madhu shukla & s. n. tripathi, effect of vegavidharna (urine vithholding) on neurohumors: (an experimental study) Ancient Science of Life Vol. VIII, Nos. 1. July 1988, Pages 55-59

186 Cha. Su. 25/40

187 Cha. Su. 25/40

188 Cha. Su. 25/40

189 ÌuÉwÉqÉÉzÉlÉqÉç AÎalÉuÉæwÉqrÉMüÉUhÉqÉç I Cha. Su. 25/40

ÌuÉwÉqÉÉzÉlÉÇ MüSÉÍcÉiÉ AsmÉqÉɧÉÇ MüSÉÍcÉiÉ AÌiÉqÉɧÉqÉzÉlÉÇ AÎalÉuÉæwÉqrÉ MüÉUhÉÇ ´Éå¸iÉqÉqÉç I aÉÇaÉÉkÉU

190 Cha. Su. 25/40

191 Srinivasan T M. Prana and electrons in health and beyond. Int J Yoga [serial online] 2014 [cited 2014 Nov 21];7:1-3.

264

Conclusions

If I have seen a little further than others it is by standing on the shoulders of giants. (Sir Isaac Newton) 07 Conclusion

Conclusions

Conceptual Study:

 Vedic & darshanik perception of Prana is as a vital breath or energy needed for actions in the form of elemental air & is characterized by consciousness & serves as a vehicle of spirit/ soul.

 Prana is a vitality element of body as well as a vata dosha. Anna pravesha (Charakacharya)/Poorana (Sushrutacharya) is function of prana vayu. Thus it is a force responsible for apt dilatation of body channels so that they can be well perfused with relevant body elements/ nutritive elements which are again given notion of bahya prana.

 The phenomenon of dilatation is resultant of heat process. Hence in Ayurvedic doctrine the subtle ‘prana principle’ & ‘prana vayu’ are said dependent on ‘agni’. In similar context it is found relevant that the ‘mahasrotas’ (site for agni) is considered as moolasthana of pranavaha srotas.

 Subtle prana is energy; it resides in Dhatu & pranayatana. Prana is dependent on agni for its sustenance. Agni in turn depends on Snigdha element which is majorly found in Dhatu. This forms core triangle of Ayurvedic Physiology.

 Phenomenon of Vilomata is seen associated with CHD.

 ‘Prana vitiation’ is an important aspect of CVD pathology in ayurvedic viewpoint.

265

07 Conclusion

Observational Study:

 Mahasrotas i.e. (Annavaha & Purishavaha) & pranavaha srotodushti hetu were found statistically significant in observational study conducted on coronary heart disease patients.

 Annavaha srotodushti lakshana were found statistically significant in observational study conducted on coronary heart disease patients.

 Vitiation of Agni is seen statistically significantly at hetu & lakshana levels in observational study conducted on coronary heart disease patients.

 Manas Hetu like Irshya, Bhaya, Krodha, Shoka are found statistically significant in observational study conducted on coronary heart disease patients.

 Thus role of ‘vitiation of Prana’ is seen in CHD pathology. Vitiation of ‘Prana’ & ‘Annavaha srotas’ are seen as prominent risk factors of CHD in Ayurvedic perspective.

 Thus there is a close physiological interrelationship amongst ‘hrudaya’, ‘mahasrotas’ & ‘prana’ as proposed in hypothesis. This relationship is explored conceptually & is seen supported by outcomes of observational in coronary heart disease individuals.

266

Summary

Perhaps the best test of a man's intelligence is his capacity for making a summary. (Lytton Strachey)

08 Summury

Summary

1) Introduction:

Alike modern sciences, Ayurvedic discipline has used many synonyms for a single element ex. some sharir bhava or herbs. Each synonym reflects its unique shade of meaning & has got its own practical application too. In classics term ‘Prana’ is used in variety of sense / meanings. Term prana is mostly used as 1st type (swaroopa) of vata dosha amongst five of them. However same term is also used as vitality element of body. Ayurveda being a holistic medicine, the concept of vitality is an important one. Hence there is a need to compile, understand and criticize all such references of prana & to clarify operational definitions in cases. It is also need of hour to put forth a comprehensive understanding of ‘prana’, as the phenomenon of ‘life’ depends on ‘prana’ itself.

Ayurvedic sharir concepts are unique & are observed in chikitsadhishthita purusha & not dead bodies. According to Charakacharya ‘hrudaya’ & ‘mahasrotas’ are moolasthana of pranavaha srotas. Consideration of ‘mahasrotas’ as a ‘moolasthana of pranavaha srotas’ in Charak samhita is very praiseworthy consideration as the classic belongs to school of physicians.

Shwas kruchhrata/ shwas is lakshana in many vyadhi as well as in swatantra ‘shwas vyadhi’. ‘Dyspnea’ is a relevant modern term.CHD (coronary heart disease) is an important disease in today’s era essentially showing dyspnea as its cardinal symptom. The traditional risk factors for coronary artery disease are high LDL cholesterol, low HDL cholesterol, high blood pressure, family history, diabetes, smoking, being post- menopausal for women and being older than 45 for men & Obesity may also be a risk factor. These factors are already proved & hence care about

267

08 Summury

these factors is advised in preventive cardiology. There is need to enlight more risk factors if any in the light of Ayurvedic theories.

In present study CHD subjects are studied with a specially designed questionnaire /case paper for the detailed functional status of mahasrotas of them. Observations of this retrospective observational study are analyzed with chi square test. Observations are thoroughly studied with ayurvedic methods of tantrayukti.

2) Review of Literature: Review of previous work done (MD/PhD) was taken.

Literature was reviewed for both tasks:

Review of Prana (Conceptual Study): Epistemological study of prana was done. References of prana from Veda, Upanishada (Shankar Bhashya), Purana, Bhagvad geeta, Bhagvatam, Darshana shastra, hath yoga Pradipika, Patanjal Yoga darshana (bhartiya manasshastra), BKS Iyangar, david frawley & many other books, Dissertations, Periodicals like Madhujeevan, Dhanwantari, Peer reviewed Journals (online & print), Old kriya books, Curricular books were reviewed.

Review of CVD & allied: Review for Hrudaya Sharir of Sira, Dhamani Sharir, Mahasrotas Sharir was done. Ayurvedic concept of Swatantra & Paratantra Hrudroga & ayurvedic relevant concepts & modern concepts about CVD were reviewed.

Review of literature for designing Questionnaire : Annavaha srotas dushti hetu (Cha.Vi.5), Purishavaha srotodushti hetu (Cha.Vi.5), Agni dushti hetu (Cha.Chi.15),Annavaha srotodushti lakshana (Cha.Vi.5), Purishavaha srotodushti lakshana (Cha.Vi.5), More important lakshana of Mahasrotas , Pranavaha srotas hetu (Cha.Vi.5, Cha. Chi.8), Rasa vaha srotas dushti hetu (Cha.Vi.5)

268

08 Summury

3) Aim & Objectives: Aim:

i. To make a fundamental understanding of term ‘prana’ in Ayurveda with literary study. ii. To explore the physiological interrelationship of ‘hrudaya’, ‘mahasrotas’ & ‘prana’, with observational study in coronary heart disease.

Objectives:

i. To compile references of term ‘prana’ from ayurvedic literature & study them in sharir kriyatmak perspective. ii. Fundamental assessment of concept of prana & ayurvedic physiological relation of prana- hrudaya- mahasrotas, and also with rasavaha & pranavaha srotas. iii. To study CHD subjects with a specially designed questionnaire for the detailed status of mahasrotas in them. iv. To explore the physiological interrelationship of hrudaya, mahasrotas & prana with help of retrospective observational study.

4) Materials & Methodology:

Materials:

i. All classics (brihat trai & allied), related ayurvedic books & periodicals of ayurveda. ii. Texts of medical physiology & relevant parts of cardiology from books of pathology & medicine.

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iii. Specially designed case paper / questionnaire of retrospective observational study. iv. 150 prediagnosed patients of coronary heart disease.

Methodology:

i. All classics (brihat trai & allied), related ayurvedic books & periodicals of ayurveda & texts of medical physiology & relevant parts of cardiology from books of pathology & medicine will be studied & comprehensive understanding ‘prana’ is postulated with this fundamental literary study. ii. Examination of mahasrotas of 150 prediagnosed coronary artery disease (diagnosed with angiography) patients with especially designed case paper / questionnaire was done. iii. Appropriate statistical tests of association i.e. chi square test is applied to interpret data & conclusions are drawn. iv. ‘Physiological interrelationship of ‘hrudaya, mahasrotas & prana’ is explored.

 Source of Data: 150 pre diagnosed patients (coronary angiography done) of coronary heart disease were selected from Bharati Medical Foundation’s hospitals & other Pune based hospitals & Ayurvedic clinics. Written consent was obtained from patients before observational.

 Inclusion criteria: . Patients prediagnosed for CHD after coronary angiography. . Single / bi / tri vessel disease with one of blockage not less than 35%. . Both male & female will be included.

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. Age 30- 60 years of age, both male & female. . Patients of CHD those have undergone angioplasty within 03 months.

 Exclusion criteria: . Patients of CHD with other major systemic disease. . Patients of CHD with DM. . Patients of CHD with all kinds of acute conditions. . Patients taking medication for gastrointestinal complaints. ex. laxatives, antacids, or ayurvedic preparations /therapies for same.

. Hypothesis: . Hrudaya & mahasrotas are moolasthana of one & same srotas i.e. pranavaha srotas. Asssociation of these two might be reflected in pranavahasroto dushti ex. CHD. Retrospective observational study of CHD subjects may be fruitful in same regards. And thus physiological interrelationship of hrudaya, mahasrotas & prana can be explored.

5) Observations:

 All of 3 factors of Annavaha srotas dushti hetu show significant relation.  Three factors of Purishavaha srotas dushti hetu whereas ‘krushtwa’ shows significant relation.  Six factors of agni vitiation Abhojana, guru, rooksha, sheeta, sandushta bhojana & vega dharana show significant association. Whereas 4 lakshana i.e. Vishamashana & Asatmya bhojana, Shodhana & vyadhi karshana show non-significant relation.

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 3 lakshana of annavaha srotodushti i.e. Annanabhilasha, Aruchi, Avipak show significant association whereas chhardi show non- significant relation.  Three Lakshana like atigrathita, alpalpa & krruchhra purisha are seen in significant association whereas 3 sashabda, sashoola & ate bahu purisha lakshana are seen in non-significant relation.  Lakshana like Aasyavairasya, Udar daha, aadhman, aatop, aanah, vishtambha, Gala vidaha are seen in significant association. Whereas amlak & urodaha do not show significant relation.  Among manas bhava, 4 of them Irshya, bhaya, shoka, krodha show significant relation. Whereas hetu, utkantha shows non- significant relation.  Pranakshyakara hetu like Ati maithuna, sandharana, raukshya, Kshudhitasya vyayama, Daruna karma show positive association whereas anashana shows non-significant relation.  All of 5 Rasa dushti hetu Guru bhojana, Sheeta bhojana, Ati snigdham, Ati matram, Chintyanam Ati chintana are seen in significant relation.

6) Discussion:

It is divided in two subchapters.

A) Conceptual Study of ‘Prana’

B) Discussion on Ayurvedic viewpoint of CVD & Observational Study

A) Conceptual Study :

 Prana is a term used for vayu as well as subtle prana.

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 Subtle prana is seen equivalent with bala as per many references.

 Poorana is stated as karma of prana by Sushrutacharya,

 Poorana is filling in vacant space. This is either by absorption generating space or by secretion of different constituents. The concept of Poorana quite resembles with concept of Perfusion. Thus proves that action of Prana is centrifugal as reported by Vd. Nanal Ramesh.

 The phenomenon of poorana is again related with apt dilatation of concerned srotas. The dilatation is result of heat process. Thus subtle prana is dependent & also nourished by agni principle.

 The general treatment for pranavaha srotas resembles with disease shwasa which originates from amashaya. The term amashaya also mentioned as synonymous with mahasrotas. Shwasa originates in mahasrotas (Cha.Chi. 17). On account of this similarity and this clinical point of view mahasrotas as mulasthan of pranavaha srotas is justified here with.’ (Panja asitkumar et.al )

 Some important relationships:

 Prana- Rakta share a very close association that shuddha shonita can not occur without prana & vice versa.

 Prana- Basti: Basti is considered to be place of prana according to Sushrutacharya.

 Prana-Asthi-majja: Vitiation of Prana & agni is a symptom when visha enters asthi dhatu.

 Shirastha/Urastha Prana debate is reviewed & discussed.

 Concept of 12 Prana by Sushruta is explored.

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 Prana-Agni-Ahar relationship is discussed as ahara itself is bahya prana.

 Prana-Indriya-Mana relation is discussed. Prana is a bridging between sharir guna & aatma guna. On its one side resides subtle elements like mahat, aatma ,mana whereas on other side are dosha, dhatu & mala.  Factors for subtle Prana kshaya vruddhi are reviewed & discussed.  Prana is other medicines is discussed

B) Discussion on Ayurvedic viewpoint of CVD

 Along with subtle prana, Prana vayu too is closely associated with hrudaya.  Hrudaya-Mahasrotas interrelationship is discussed well. Ex. Hetu of Gulma are same as that of hrudroga, says Vagbhata.  Prana vayu is closely associated with mahasrotas physiology. It’s role is far more than ‘Apakarshana of anna’.  Thus Ayurvedic viewpoint of CVD is a Collage of viloma vata, vitiated/diminished prana, dushta annavaha srotas & pranakshayakara elements.

Observational Study: Distribution table & Chi square test both were applied & discussion was made.

 All Annavaha srotas dushti hetu (100%) show significant association. Thus the relationship of physiological relationship of Hrudaya-aamashaya-kapha is established. Whereas 75% of annavaha sroto dushti lakshana show relation.  83.3% Purishavaha srotas dushti hetu show association, This underlines prana-apana relationship. Kruchra & grathita purisha

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indicate chronic constipation & thus role of viloma vata is underlined. However only 57% symptoms of purishavaha srotdushti show relation.  60% agni vitiation hetu Abhojana, guru, rooksha, sheeta, sandushta bhojana & vega dharana & lakshana of agni dushti 77.7% show significant relation. This again reclaims the relationship of prana- agni as mentioned in hypothesis.  Lakshana like Aasyavairasya, Udar daha, aadhman, aatop, aanah, vishtambha, Gala vidaha are seen in significant relation. Whereas amlak & urodaha do not show significant relation.  Except Utkantha remaining all manas bhava Irshya, bhaya, shoka, krodha show significant association. Other Pranakshyakara hetu like Ati maithuna, sandharana, raukshya, Kshudhitasya vyayama, Daruna karma show positive association whereas anashana shows non-significant association. Thus 81.8% hetu of pranavaha sroto dushti are seen in significant association. Thus interrelationship of subtle prana & prana vayu is discussed.  All of 5 Rasa dushti hetu i.e. 100% hetu including Guru bhojana, Sheeta bhojana, Ati snigdham, Ati matram, Chintyanam Ati chintana are seen in significant association. This again underlines pathophysiological relations between amashaya-rasa-hrudaya. Conclusions:

Conceptual Study:

 Vedic & darshanik perception of Prana is as a vital breath or energy needed for actions in the form of elemental air & is characterized by consciousness & serves as a vehicle of spirit/ soul.

 Prana is a vitality element of body as well as a vata dosha. Anna pravesha (Charakacharya)/Poorana (Sushrutacharya) is function of prana vayu. Thus it is a force responsible for apt dilatation of

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body channels so that they can be well perfused with relevant body elements/ nutritive elements which are again given notion of bahya prana.

 The phenomenon of dilatation is resultant of heat process. Hence in Ayurvedic doctrine the subtle ‘prana principle’ & ‘prana vayu’ are said dependent on ‘agni’. In similar context it is found relevant that the ‘mahasrotas’ (site for agni) is considered as moolasthana of pranavaha srotas.

 Subtle prana is energy; it resides in Dhatu & pranayatana. Prana is dependent on agni for its sustenance. Agni in turn depends on Snigdha element which is majorly found in Dhatu. This forms core triangle of Ayurvedic Physiology.

 Phenomenon of Vilomata is seen associated with CHD.

 ‘Prana vitiation’ is an important aspect of CVD pathology in ayurvedic viewpoint.

Observational Study:

 Mahasrotas i.e. (Annavaha & Purishavaha) &pranavaha srotodushti hetu were found statistically significant in observational study conducted on coronary heart disease patients.

 Annavaha srotodushti lakshana were found statistically significant in observational study conducted on coronary heart disease patients.

 Vitiation of Agni is seen statistically significantly at hetu & lakshana levels in observational study conducted on coronary heart disease patients.

 Manas Hetu like Irshya, Bhaya, Krodha, Shoka are found statistically significant in observational study conducted on coronary heart disease patients.

 Thus role of ‘vitiation of Prana’ is seen in CHD pathology. Vitiation of ‘Prana’ & ‘Annavaha srotas’ are seen as prominent risk factors of CHD in Ayurvedic perspective.

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 Thus there is a close physiological interrelationship amongst ‘hrudaya’, ‘mahasrotas’ & ‘prana’, which is explored conceptually & is seen supported by outcomes of observational in coronary heart disease individuals.

277

Bibliography

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(Francis Bacon)

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Electronic Database:

 Ayusoft, CDAC, Pune  AYUSH Portal  Jamnagar thesis: database on CD by Dr. Girish KJ  http://shodhganga.inflibnet.ac.in/  Vaidyaraj Gold – Software for Ayurveda Clinics, by Vaidya Rasik S Pawaskar, Nirmitte Computers, 29, ‘MANASI’, Lane no 9, Survey no 35, Natraj Society, Karve Nagar, Pune – 52.

Web Resources:  Google Books  Google scholar  Scopus database  Inflibnet  Delnet  http://niimh.nic.in/ebooks/ecaraka/  http://niimh.nic.in/ebooks/esushruta/  http://niimh.nic.in/ebooks/e-Nighantu  http://niimh.nic.in/ebooks/madhavanidana

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Questionnaire

Case. No.: Date: ___/___/___ Patient Name: ______Address: ______

Age: ______yrs. Wt.: ____ kg. Occupation: ______Religion: ______Brief report of coronary angiography: ______

Part I Mahasrotas Parikshana Part II (A) Pranavaha srotas Parikshana Part II (B) Rasavaha srotas Parikshana Part III Casepaper for signs & allied symptoms

Part I (Mahasrotas Hetu Parikshana)

A) ANNAVAHA SROTODUSHTI HETU: I. A. 1 Atimatrasya bhojanat: How often you take meals in such a large quantity that it do not get digested in 5-7 hours or gives you a feel of heaviness in abdomen or tightness towards chest region? a) Rare b) 1/7 days c) 2-3/ 7 days d) 4-5/ 7 days e)almost daily i.e. 6-7/7days

I. A. 2 Akale bhojanat:

Questionnaire i

Do you feel hungry or feeling of lightness before having meals/something? Is your lunch in between 10 am to 1pm & dinner between 6pm to 8pm? If not, specify your time. a) Rare b) 1/7 days c) 2-3/ 7 days d) 4-5/ 7 days e)almost daily i.e. 6-7/7days Time of lunch: I. A. 3 Ahitasya bhojanat : Tick the food items (from list) you regularly consume them. Also mention the frequency & quantity. Kusumbha taila(kardai tel) , Bamboo shoots, Alu bhaji , Kasalu bhaji, ushara lavana, Masha, Apakwa moolak, Sarshap leaves, Mandak dadhi, Dadhi. Maida derivatives, Bread, Biscuits, Pizza, Cheese, Paneer, Excess salt, Namkins , Chinese food, packed food with presertives. a) Yes b) No c) Had Previously Frequency: & Quantity:

B) PURISHAVAHA SROTODUSHTI HETU: I. B. 1 Purisha vega vidharanat: How often you suppress/ neglect natural urge of defecation? (because of not having time / work pressure/ else inconveniences) a) Rare b) 1/7 days c) 2-3/ 7 days d) 4-5/ 7 days e)almost daily i.e. 6-7/7days I. B. 2 Atyashanat: How often you take meals in such a large quantity that it do not get digested in 5-7 hours or gives you a feel of heaviness in abdomen or tightness towards chest region? a) Rare b) 1/7 days c) 2-3/ 7 days d) 4-5/ 7 days e)almost daily i.e. 6-7/7days I. B. 3 Ajeernadhyashanat:

Questionnaire ii

How often you take some food beverages, deserts, sweet dishes or else eatables even after having full stomach lunch? Or take other food stuff within 3-4 hours after meals even previous is undigested? a) Rare b) 1/7 days c) 2-3/ 7 days d) 4-5/ 7 days e)almost daily i.e. 6-7/7days I. B. 4 Doorblagni: Do you suffer from indigestion frequently? Even after having taking less or light food stuff? a) Yes b) no I. B. 5 Krushatwa: BMI of patient = weight in kg/ height in m2. (1meter = 100cm) Weight: Height: Is BMI less than 18.5 i.e. is individual krusha? a) Yes b) No

C) AGNI DUSHTI HETU: I. C. 1: Abhojanat: How many times a week, you follow fast (having no food/ having only liquids)? or a lunch is skipped because of else reasons? a) Rare b) 1/7 days c) 2-3/ 7 days d) 4-5/ 7 days e)almost daily i.e. 6-7/7days I. C. 2: Vishamashana: Are your food quantities irregular? Sometimes very less n sometimes more quantity of food? a) Yes b) No I. C. 3: Asatmya bhojana: Do you eat some specific food in spite of knowing its tolerance to you? Ex. Some people may have intolerance with toor dal, icecream, horse gram etc. b) Yes b) No I. C. 4 : Guru bhojana:

Questionnaire iii

Tick any of following food items if you consume them. Also write the frequency & quantity of them. Raj masha, Nishpva, kushmanda, Trapus, Alabu, Shami phala , Madhu, Buffalo milk/ ghee, milk derivatives like shreekhand, amrakhanda, basundi, pedha, malai sweets Paneer, dahi, mamsa, matsya, egg, maida derivatives like gulabjamun, mango juice, fried foods. a) Yes b) No Frequency: Quantity: I. C. 5: Sheet bhojanat: i) How many times you have to take sheeta (cool) bhojana? Do you take chilled water / cold beverages / freezed stuffs like icecreams? a) Rare b) 1/7 days c) 2-3/ 7 days d) 4-5/ 7 days e)almost daily i.e. 6-7/7days I. C. 6:Ati rooksha bhojanat: Tick any of following food items if you consume them. also write the frequency & quantity of them. Yava, mudga, makustha, chanak, masoor, harenu, chanak , shimbi dhanya, Churmura, bread a) Yes b) No Frequency: Quantity: I. C. 7 : Sandushta bhojanat: Do you take food preparations from unhygienic / less hygienic outlets? a) Rare b) 1/7 days c) 2-3/ 7 days d) 4-5/ 7 days e)almost daily i.e. 6-7/7days I. C. 8 : shodhana vibhrama: Did you have history of some complications during panchakarma treatments taken by you (if any)? a) Yes b) no details: I. C. 9: Vyadhi karshanat: Have you & how many times (till date) you have suffered from major weakness/weight loss followed by some major illness? (Ex. Month long weaknesses followed by typhoid, jaundice etc.)

Questionnaire iv

Ans.: a) YES b) NO If yes details: I. C. 10 : Vega vidharanat: For how many times you need to suppress/ neglect natural urges like urine, yawning, sneezing , udgar, etc. for some of time ? (May because of running out of time / other inconveniences) a) Rare b) 1/7 days c) 2-3/ 7 days d) 4-5/ 7 days e)almost daily i.e. 6-7/7days

D) ANNAVAHA SROTODUSHTI LAKSHANA: I. D. 1: Anannabhilasha: Do u have a feeling of anorexia? i.e. you have an appetite but don’t have desire for food? a) Rare b) 1/7 days c) 2-3/ 7 days d) 4-5/ 7 days e)almost daily i.e. 6-7/7days I. D. 2: Aruchi: Do you suffer from inability to have food (because of tastelessness) in spite of having a desire for food? a) Rare b) 1/7 days c) 2-3/ 7 days d) 4-5/ 7 days e)almost daily i.e. 6-7/7days

I. D. 3: Avipak: Did your food get digested in 5-6-7hours? (Judge it by having feeling of lightness, clean udgar, some vega of mutra/ mala, freshness/ enthusiasm as indicators of digestion.) a) Rare b) 1/7 days c) 2-3/ 7 days d) 4-5/ 7 days e)almost daily i.e. 6-7/7days I. D. 4: Chhardi : Do you suffer from nausea / vomiting? a) Rare b) 1/7 days c) 2-3/ 7 days d) 4-5/ 7 days e)almost daily i.e. 6-7/7days

Questionnaire v

E) PURISHAVAHA SROTODUSHTI LAKSHANA:( charaka viman 5) I. E. 1 : Krucchra Purisha : Do you need to do pravahana (groan) for a successful excretion of fecus? a) Rare b) 1/7 days c) 2-3/ 7 days d) 4-5/ 7 days e)almost daily i.e. 6-7/7days I. E. 2 : Alpalpa Purisha : Is the quantity of purisha considerably less? a) yes b) no I. E. 3 : Sashabda Purisha : Is there shabda i.e.some sound during mala pravrutti? a) Rare b) 1/7 days c) 2-3/ 7 days d) 4-5/ 7 days e)almost daily i.e. 6-7/7days I. E. 4 :Sashoola Purisha : Is the process of defecation painful? If yes specify whether pain is anal/ lower abdominal? a) Rare b) 1/7 days c) 2-3/ 7 days d) 4-5/ 7 days e)almost daily i.e. 6-7/7days I. E. 5 :Atee Drava Purisha : Is the constituency of purisha liquid ? a) Rare b) 1/7 days c) 2-3/ 7 days d) 4-5/ 7 days e)almost daily i.e. 6-7/7days I. E. 6 : Atee Grathita Purisha : Do you suffer from hard stools? a) Rare b) 1/7 days c) 2-3/ 7 days d) 4-5/ 7 days e)almost daily i.e. 6-7/7days

I. E. 7 : Atee Bahu Purisha : Is the quantity of purisha considerably more? a) yes b) no

F) SOME MORE IMPORTANT LAKSHANA:

Questionnaire vi

I. F. 1 Aasyavairasya: Does u have complaint of tastelessness / altered tastes? a) yes b) no I. F. 2 Amlak: Do u suffer from amla udgar / amla udirana? a) yes b) no I. F. 3 Urodaha Do you have chest burn? a) yes b) no I. F. 4 Udar daha Do you have burning sensation in abdomen? a) yes b) no I. F. 5 Aadhman Do you suffer from gases in abdomen? a) yes b) no I. F. 6 Aatop Do you suffer from gud-gud sound in abdomen? a) yes b) no I. F. 7 Aanah Do u suffer from tension in abdomen & constipation? a) yes b) no I. F. 8 Vishtambha Do you suffer from constipation as well as obstruction in passing of gases? a) yes b) no I. F. 9 Gala vidaha Do you have burning in throat? a) yes b) no

Part II

Questionnaire vii

(A) (Pranavaha srotas Hetu Parikshana) Kshayat: II.A.1) Irshya:

1) Would you be happier and more secure and worthy if you had what the other have. (This could mean the other’s spouse, house, appearance, abilities, knowledge, power etc.) a) Always Yes b) Often yes c) Often No d) Never

2) Do you often think that others are better than you in any of contexts? a) Always Yes b) Often yes c) Often No d) Never

3) Do you feel diminished by someone’s beauty, brains, or accomplishments? a) Always Yes b) Often yes c) Often No d) Never

IRSHYA: a) No b) grade 1 c) grade 2 d) grade 3 e) grade 4

II. A. 2) Utkantha:

How often have you been bothered by following problems?

1) Feeling nervous, anxious or on edge? a) Not at all b) several days c)more than half days d)almost every day 2) Not being able to stop or control worrying? a) Not at all b) several days c)more than half days d)almost every day 3) Being so restless that it is hard to sit still. a) Not at all b) several days c)more than half days d)almost every day 4) Becoming easily annoyed /irritable.

Questionnaire viii

a) Not at all b) several days c)more than half days d)almost every day

UTKANTHA: a) No b) grade 1 c) grade 2 d) grade 3 e) grade 4

II. A. 3) Bhaya:

1) Do you often find yourself distressed and anxious, but are unable to put your finger on the problem?

a) Always Yes b) Often yes c) Often No d) Never

2) Do you have specific fears you can identify and would like to overcome?

a) Always Yes b) Often yes c) Often No d) Never

3) When faced with situations or things that frighten you, do you become nervous and too paralyzed to act?

a) Always Yes b) Often yes c) Often No d) Never

4) Do you over concern about the health and safety of your friends and family?

a) Always Yes b) Often yes c) Often No d) Never

BHAYA: a) No b) grade 1 c) grade 2 d) grade 3 e) grade 4

II. A. 4) Shoka

1) Have your sleeping patterns changed considerably since the significant loss of resources/assets of your life? a) Always Yes b) Often yes c) Often No d) Never 2) Have you been unable to concentrate since since the significant loss of resources/assets of your life? a) Always Yes b) Often yes c) Often No d) Never

Questionnaire ix

3) Have others told you that you are not coping well since the significant loss of resources/assets of your life? a) Always Yes b) Often yes c) Often No d) Never

SHOKA: a) No b) grade 1 c) grade 2 d) grade 3 e) grade 4

II. A. 5) Krodha:

1) I usually do not get angry a) Always Yes b) Often yes c) Often No d) Never

2) Even when the other person gets angry with me, I stay calm a) Always Yes b) Often yes c) Often No d) Never

3) I find it hard to stop thinking about what happened a) Always Yes b) Often yes c) Often No d) Never

4) I swear, or curse at the person who made me angry a) Always Yes b) Often yes c) Often No d) Never

5) When I get angry, everything feels out of control a) Always Yes b) Often yes c) Often No d) Never

KRODHA: a) No b) grade 1 c) grade 2 d) grade 3 e) grade 4

II. A. 6) Anashana How many times a week, you follow fast (having no food/ having only liquids)? or a lunch is skipped because of else reasons? a) Rare b) 1/7 days c) 2-3/ 7 days d) 4-5/ 7 days e)almost daily i.e. 6-7/7days II. A. 7) Ati maithuna : Specify the current & previous frequency of intercourse Current ………………… Previous ……………………….

Questionnaire x

Do u suffer from ‘daurbalya’ after intercourse in some of last years? a) Yes b) No II. A. 8) Sandharanat: For how many times you need to suppress/ neglect natural urges like urine, yawning, sneezing , udgar, etc. for some of time ? (May because of running out of time / other inconveniences) a) Rare b) 1/7 days c) 2-3/ 7 days d) 4-5/ 7 days e)almost daily i.e. 6-7/7days II. A. 9) Raukshyat: i) Do you apply oil to skin? How often? a) No b) seasonally winter/ summer c) once in 15 days d) once in 7 days e) almost daily ii) Rooksha bhojana: Tick any of following food items if you consume them. also write the frequency & quantity of them. Yava, mudga, makustha, chanak, masoor, harenu, chanak , shimbi dhanya, Churmura, bread iii) How often you have late sleep? (i.e. after 11 pm) Raukshya: a) Yes b) No

II. A.10) Vyayamat Kshudhitasya: Do u exercise/ exert when you are hungry? a) Yes b) No II. A.11) Darun karma: Do you continue your physical or mental or intellectual activities (exercise/ exertion) to extended durations even after knowing that your stamina is over & you need rest (physical & mental). a) Yes b) No Part II (B) (Rasavaha srotas Hetu Parikshana)

Questionnaire xi

II. B. 1) Guru:. Tick any of following food items if you consume them. Also write the frequency & quantity of them. Raj masha, Nishpva, kushmanda, Trapus,Alabu, Shami phala , Madhu, Buffalo milk/ ghee, milk derivatives like shreekhand, amrakhanda, basundi, pedha, malai sweets Paneer, dahi, mamsa, matsya, egg, maida derivatives like gulabjamun, mango juice, fried foods. a) Yes b) No Frequency: Quantity: II. B. 2) Sheeta: i) How many times you have to take sheeta (cool) bhojana? a) Rare b) 1/7 days c) 2-3/ 7 days d) 4-5/ 7 days e)almost daily i.e. 6-7/7days ii) Do you take chilled water / cold beverages / freezed stuffs like icecreams? a) Rare b) 1/7 days c) 2-3/ 7 days d) 4-5/ 7 days e)almost daily i.e. 6-7/7days

II. B. 3) Ati snigdham: Tick any of following food items if you consume them. Also write the frequency & quantity of them. Fried eatables, excess use of oil, excess use of ghee, mahisha dugdha, a) Yes b) No Frequency: Quantity: II. B. 4) Ati matram: How often you take meals in such a large quantity that it do not get digested in 5-7 hours or gives you a feel of heaviness in abdomen or tightness towards chest region? b) Rare b) 1/7 days c) 2-3/ 7 days d) 4-5/ 7 days e)almost daily i.e. 6-7/7days II. B. 5) Chityanam cha ati chintanat: Do you habitually think a lot on a particular issue to a troubling extent?

Questionnaire xii

a)Yes b) No

Questionnaire xiii

III) Casepaper for signs & allied symptoms

Pulse: Blood Pressure: Nadi: Jivha: Mootra: Mala: Sweda: Nidra: Menstural History: History of Major illness:

History of present illness:

Associated symptoms:

Case no. Signature of Scholar Signature of Guide

Questionnaire xiv

idnaMMak saMmataIpa~a

maI ------vaOÒ pa`saad paaMDkxr yaaMcyaa saMSaaoQana pa`kxlpaamaQyao svaocConao sahBaagaI haota Aaho. yaa pa`kxlpaacaI saMpaUNa_ maaihtaI vaOÒ pa`saad paaMDkxr yaaMnaI malaa idlaI Aaho. =dyaraogaaSaI saMbaMiQata ho saMSaaoQana AsaUna tyaasaazxI AavaSyak Asalaolao pa`Snapa~a maI kxaoNataahI dbaava na Gaotaa Bar}na dota Aaho.

r}gNanaama – svaaXarI -

PARTICIPANT INFORMATION SHEET

INTRODUCTION:

Coronary heart diseases (CHD) have reached epidemic proportions among Indians. India is undergoing a rapid health transition with rising burden of CHD with a two-fold rise in rural areas and a six- fold rise in urban areas between the years 1960 and 2000 particularly in last two decades. Studies among Indian migrants in various parts of the world have documented an increased susceptibility to CHD in comparison to the native population studied. Prevention is based on causative factors. The traditional risk factors for coronary artery disease are high LDL cholesterol, low HDL cholesterol, high blood pressure, family history, diabetes, smoking, being post-menopausal for women and being older than 45 for men & Obesity may also be a risk factor. These factors are already proved & hence care about these factors is advised in preventive cardiology.

However according to Ayurved, status of mahasrotas (alimentary canal) is closely with cardiac physiology. Hence scholar will work on association of status of mahasrotas in already diagnosed coronary heart disease patients. So that physiological interrelationship of hrudaya, mahasrotas & prana will be explained. And study outcomes may reveal some association between status of mahasrotas (alimentary canal) with coronary heart disease, which may be useful for further works on preventive cardiology.

Participant Information sheet a

PURPOSE OF STUDY: To study the association between coronary heart disease & status of mahasrotas (alimentary canal), as mahasrotas is moolasthana of pranavaha srotas along with Hrudaya. And to explore physiological interrelationship of hrudaya, mahasrotas & prana will be explained.

CONFIDENTIALTY OF YOUR PARTICPATION: Your identity and personal information will be kept confidential. It will be revealed only to the competent authority or ethical committee members.

YOUR POTENTIAL RIGHTS AND RESPONSIBILITS AS A PARTICIPANT: Along with the decision about your participation and maintenance of confidentiality, you have the right to question the investigator about the data being collected and its purpose. At the same time you are expected to co-operate with the investigator during data collection and examination procedure.

INFORMED CONSENT: After you are through with this information sheet and fully satisfied, you will be asked to sign a consent form to confirm your voluntary participation in the study.

PROCEDURE OF DATA COLLECTION: Personal information: Data will be collected about your name, age, occupation, family history, dietary habits etc. This information may be processed manually or electronically and analyzed to determine the outcome of the study.

Participant Information sheet b

Medical & cardiovascular history: You will be asked about your past and current medical & cardiovascular conditions. You should also inform investigator about any medicines that you are taking. You should also give a photocopy of reports of angiography of you. Special case paper/ questionnaire : You will be asked questions about diatery habits, lifestyle factors, details of complaints (if any) of mahasrotas (alimentary canal) with detailed nature of them & duration & frequency of them.

NAME OF RESERACHER: Dr. Prasad Dilip Pandkar

NAME OF SITE AND ADDRESS: Department of Kriya Sharir, Bharati Vidyapeeth Deemed University, College of Ayurved, Pune-43

Participant Information sheet c

INFORMED CONSENT FORM

I confirm that I have read and understood the Participant Information Sheet dated …………………for the above study and have 1 had the opportunity to ask questions and am satisfied with the responses received.

I understand that my participation in the study is voluntary and that 2 I am free to withdraw at any time from the study without giving any reason and without affecting my medical care or legal rights.

I understand that the researcher /others working on behalf of researcher, the Ethics Committee and the regulatory authorities will not need my permission to look at my records, both in respect of the 3 current study and any further research that may be conducted in relation to it. Even if I withdraw from the study, I agree to this access. However I understand that my identity will not be revealed in any information related to third parties or publications.

I agree not to restrict the use of any data or results that arise from 4 this study provided such a use is only for scientific purpose(s).

I consent voluntarily to participate as a participant in the above 5 research study. Name of participant: Signature of participant:

Signature of researcher: Signature of Guide:

Date:

Participant Information sheet d

Name of Patient case no. I. A. 1 I. A. 2 I. A. 3 I. B. 1 I. B. 2 I. B. 3 I. B. 4 I. B. 5 I. C. 1 I. C. 2 I. C. 3 I. C. 4 I. C. 5 I. C. 6 I. C. 7 I. C. 8 I. C. 9 I. C. 10 I. D. 1 I. D. 2 I. D. 3 I. D. 4 I. E. 1 I. E. 2 I. E. 3 I. E. 4 I. E. 5 I. E. 6 I. E. 7 I. F. 1 I. F. 2 I. F. 3 I. F. 4 I. F. 5 I. F. 6 I. F. 7 I. F. 8 I. F. 9 II. A. 1 II. A.2 II. A.3 II. A.4 II. A.5 II. A.6 II. A.7 II. A.8 II. A.9 II. A.10 II. A.11 II. B. 1 II. B. 2 II. B. 3 II. B. 4 II. B. 5 Mr Tanaji Sawant 1 c c a b c c a b c b b a a a c b b a b a b a b aaaaababbaaaaabbaecccaaaaaaaaca Mr Govind Hulawale 2 d b a c d e b a e a b b b bbbabcbcbcbebacbbbaababbacbeddebbababbadb Mr Sampatlal Late 3 a c a e a d a b c b b a c a d b b c e c e a d aaaabbabbaabaabaebaecacbaaacbaa Mr ChandrakumarWaghmare 4cccbccbbaabbcabbbabcbaaaabacaaaabbabaabecccabaabbbcacb Mr Prakash Oval 5 a b a c a d a b e b a a b a c b a b c b c b c b c a a dbbbbaababbcddadeabaaaabaaa Mrs Krishnabai Mahadik 6 c c a e c e a a d a b a c a d b b c e c e a e a a c c a b a b b aaabaadaeaadacbbaacbca Mrs Shephali sayyad 7 d e b c d e b b c b a a c a b b b a c c c bbbaaaeabaaaababbbbaabcbaaaaacadb Mrs Kalawati Paradhe 8 c b a b c d b a d b b a b a c b b b bbbacaebeebabbbbabaacebccdbbbbbabbcb Mrs Chillawadi Durgappa 9 a c a e a c a b b b b a a b a b a c e a e a d b aaabababaababbddcadbacaaaaaaaa Mr Sunil Dimble 10 d e a c d e b b e a b a e a b b b d c a c b aaaacdbabbbbababdeddaebdabbaeadb Mr Chandrakant Paradkar 11 c c a e c e a b c b a a b b c b a a e b e a c b c e aaabbaaaabaaaaeabcaaaaaabaca Mrs Malan Karande 12 a e b c a e a a e b b a b a b b b b c b c a d aaaaebabbbbbabbdbaaceabbbaabbaa Mrs Shaila Gaikwad 13 c c a b c c b b c a a a c a a b b c b c b aaaabadbabaaaababbebadcbcaaaacacb Mr baban Sonawane 14 a b b c a d a b e b b a c a b b b a c c c a c b c a a bbbbbbbaabbcdcaaeaabbaacbaa Mrs Shobha Gaikwad 15 d c a e d e a b b b b a b b c b a b e b e b e a e b e d a a b bbbababdaddbbabaaaabada Mrs Suvarna Phalke 16 c c b b c c b a e a b a a a b b b c b a b a c aaaaababaaababbabeaeebcbbaaabcb Mr Pundalik Kharat 17 e e a c e e a b c b b a e a a b b a c a c a b b a b a bbbabbbababbeaeccaaaabaeaea Mr Ramchandra Jagtap 18 c b a e c d b b e a b a b bdbabebeaeacaaababbaababbcaeadebbabaabacb Mr Nishikant Thorat 19 d e c c d c a a e b b a a a b b b c c a c a c aaaeebababbaaabadbdeeacaabaaada Mr Pradip Bhilange 20 c b a e c e b b e a b a b b c b b d e b e a d b aaabbbabaabbbbbacceebdbbaabbcb Mr Sachin Thorat 21 b c a b b e a a a b a a e a b b b d b a b aaaebaebabaaaaaaacbdbcaadaaaaeaba Mr Tapaswini Singh 22 d a a c d a a b b b b a b a d b a a c b c a c b aaaeababaabbabdeeddbaaabaabada Mr Nitin Bharekar 23 c c a b c e b a a b a a e b c b b b b a b a e a a d e a b a b bbbaabaadecaabbbabaebcb Mr Ankur Jain 24 d b c c d c b b b a b a b a d b a c c b c a b b c a a c a b b aaaababbabdbbbcabaabadb Mr Pankaj gaikwad 25 d c a e d a a a a b a b c a c b b a e c e a c a a e a b b a b bbbbabacbcdcaaababbcbda Mrs Sridevi Metri 26 e c b c e a b b b b b a c a b b b b c c c bdbaaacabbaaaababdcdedbbbabaacaeb Mrs Kunda Jadhav 27 c a c e c e a b a a a b e a d b b c e a e aaaebbcbaabbbbabbadbcaaacaaabeaca Mrs Reshma Majuvar 28 b c a e b c a b b b b a a a b b a a e a e a c aaaabbaabaaaaaadecbbbaaabaaaaba Mr Kulkarni dattatraya 29 d e c c d a b a a b a b c b c b b b c c c bbbdbbabbabaaababbaddcabbbabbcbdb Mr Dipak Agarwal 30 c b a b c e a b b a b a c a d b b c b c b a c a c a a d b aaabababbcbbcdbacabaacaca Mrs Pushpa Suple 31 b c a c b c a a a b b b b bbbadcbcbdbddcdbaabaaabaadccbaaadbaabbbba Mrs Suman Kulkarni 32 c a b e c a a b b b b a e a d b b a e a e a a b aaabbbabbbbabbbedcbbaaabbaeaca Mr Shailesh Dubey 33 d c a a d e b a a b b b e a c b b b aaaacbdbbcaaaaaaabaacdedcabbbaabebdb Mr Sonawane Dnyandeo 34 c b b c c c a b b b b a b bbbbccbcbeaaaadbaabaababbdaaadbacabbabaca Mr Shirish Dhumal 35 d c a e d b b a a b b b e a b b a a e a e a b b d c c a b a b b aaabababedeabaaaabeadb Mr Jayant Bhave 36 e e a c e a a b b b b a a a a b b b c a c b c a c a a d b a b a bbbabbdebecbababaaaaea Mr Dinkar Walgude 37 c c b b c e a a e b b b b a c b a c bbbadaadecbabbaaababbacadeacbaabbbca Mr Sudhakar Pawar 38 d c a c d e b b c a b a e a b b b a c e c b a b aaababaabbaaaacdddecbaabbaeadb Smt Devaibai Chaukhande 39 c b b a c c b a e b b a a b a b b b aaaacaebddbabbaabbabdaacaebbaaaaaacb Mrs Sunanda Jayphalkar 40 b e a e b e a b c b b b b a c b b c a b a a d b aaaaabbbbbaaabbbabbcacbbbbbbba Mr Satish chaudhari 41 d b b c d e b a e a b a b bbbadcbcaaaecdebaaaaabbbbcaadeebdaaaabadb Mr Babubhai jagdale 42 c e a b c b a b c b b b c a b a b a b c b a c b d a a e b b b b aaaaaadabcccaabbabcbca Mr Pramod Ninave 43 e c a c e c a a a b b a c b a b b b c c c a d a a bdbbaaabbababbbcedaabaaaacaea Mr Vilas kale 44 c e b a c e b b b a b b b a c b a c a b aaabdaaebbbbaabaabcedcebbcabbbbacb Mrs Anusaya Ingole 45 d b a d d e a a a b b a e bbbbadadaeaaddebababbabbbadadcaaaaaaaeada Mr Devidas Korhale 46 c c b c c a a b b a b a a a a b b b c a c a c a d a a c b a b b a a b a a b d a a a d b a b b b b a a b c a Mr Pralhad Kharat 47 e e a a e a b a a b b a b bbbbcabaadbcbdbabbaaaaaabbbaeaabcaaaabaeb Mrs Varsha Kamble 48 e c a c e c a b b a b b e a c b a a c a c b aaaaaabaabaabbaacdbebbaabbbbebea Mrs Shobha Rawat 49 c c b b c e b a a b b a b a c b b b bbbacbadccbbbbbbaaabdccacabbaaaabacb Smt Prabhadevi Godekar 50 d d a b d d a b b b b a d bbbacbdbbebcaaeabbbaabbbbbadddbacbbbadbda Mr Milind Phulsare 51 c c b c c c b a a b b a b a d b b d c b c a b b a c bbbbbbbbaaabcbeaaabdaaaabacb Mrs Lalita Thite 52 b d b e b d a b b b b b e bdbbaaeaacabaacaaabaaabaaaeabbbaaababeaba Mr sampat Bhosale 53 d e b a d d a a a b b a b a b b b b a b a b e b a e c dbbbaabbaabdebdeaabaaaabada Mrs Kalaben Singla 54 c c a c c e b b b b b b c a c b a c c c c a b a b aaababbaaabbbbacccbbcbbabcbcb Mr Tryambak Deshmane 55 e a b d e d b a a b b a c bdbbadcdbcacacdaaaaaabaabcbdedabaaaaacaeb Mrs Pratibha Kulkarni 56 c c a c c c a b b b b b d a d b b b c d c a e b a c a c a b b b a b a b b b a c e c e b a b a b b b d a c a Mrs Prabha Kanade 57 d d a e d d b a a b b a e a b b a c a e a b b a a a c e aaabaaaaabbdedcabcbaaaebdb Mr Shankar aaher 58 c c b b c e a b b b b a e a e b b a b e b a c b c c a b a b b a bbbbaacabcdbaaabaaeaca Mr ramchandra Borhade 59 e d a c e e a a d b b b e b c b b b c e c b d a b a bdbabbaaaabbabceadabbaabebea Mrs kedari Joshi 60 e c b a e c b b e b b a b a c b b c a b aaababaabbbaaabbabbddebebcabbabaeb Mr Pradip Sarthi 61 c c a c c e a a d b b b c a e b a d c c c a c a b a d e a a b b aaaabbcdaacdadaaabcaca Mr Jayant Pingale 62 d d a e d d a b e b b a c a b b b a a c a ddbadabbbaabbbbabaaaddeaaabaacada Mrs Rohini Yardi 63 c a b b c e b a d b b b b b c b a b bbbaaabadebabbaaaabaabbaedbbbabbbbcb Mrs Shruti Junjal 64 b a a c b c a b e b b a e a b b b c c e c d c a c e a e b a b bbbbbabbdcbeeacabaaeaba Mr sahilesh Sharma 65 d d b a d e b a d b b b e a c b b a a e a ddbaadebabbaaaaabcaddcdbababbebdb Mr Dnyaneshwar Jadhav 66 c c a a c b a b a a b a b b a b a b a b aaaabaaeaaabbbaabaabacdaababaabaca Mr vasant Paradkar 67 e a b c e c b a b b b b c a b b a c c c c b c a a d d a b a b aaabbabbeaeebbcbaabcbeb Mrs Kusum Gole 68 c d a d c b a b a b b a c b a b a a d c d a a b b a a c a a b b a b a a a a c e b c e a a a a b a a c a c a Mrs Jayantidevi Pardesi 69 d a a c d e a a b a b a b a c b a b c b c b e a c b d e aaabbbbbabaacdcbabaababada Mr Vinay Dahibate 70 c d b a c b a b a b b a b a b b b c a b a a c a e a a b a a b aaaaabbdbdbdaacabaabaca Mrs Surabhi Pansare 71 b a a d b e a a b b a b e b e b a d d e d a d b a d b e aaabbbababbddbabadbabbebba Mr Hansraj Pathak 72 d b c c d c a b a a b a e a e b b d c e c b aaaaacaabaaabaabccedbaadabaaeada Mr Ramdeo Sahani 73 c b a a c b b a b b a b b b e b b a a b a a c b a c b a b a b bbbababdabccbbaaaabbacb Mr Ismail Sheikh 74 e d a c e e a b a a b a d a b b a b c d c b c aaaaebabbaababbabcbdaabbbaadbea Mr Yogesh Joshi 75 c a c d c b a a b b b a d b c b b c dddaababbdbabaaaabaadddbebacaabadaca Mrs nanda Hirve 76 d c a b d c b b a a b a b a e b b a bbbdeaceabaaabaabaabbcddeababbaabbdb Mr Manik Jadhav 77 b a b a b b a a b b a a e b c b b b a e a a c b a a c a b a b a b b a b b a c d e b e b a b a a a a e a b a Mr Ravindra Kapare 78 c c a b c e a b a b b b b a b b a c bbbadbaaacbaabaabaabaabccaacabbbbaca Mrs Nisha Kotasthane 79 d c b b d b b a b b a a e b a b b a b e b aaaacbdaababbabbbabcddbbaaaaaeadb Mrs Reema Kanojia 80 c d a c c c a b a a b b b a b b a b c b c a c b aaaabaabaaaaaaaddbaaabbbbbbbca Mrs Mayura kale 81 b c a d b b b a b b b a d a a b b c d d d c d a c bbdaababbbbbbbc abbbbcaaaadabb Mr lakshman Dhumal 82 c d a b c e a b e b a a b b c b b d bbbaaacaaababbaaaaabcdaaceadbbaabbca Mr Vishwanath gaikwad 83 d b a c d c b a c a b a c a b b a a c c c a c b a c c b a b a b a a b b a b a a a d d c b a a a a a c a d b Mrs Manisha Vekhande 84 e c b a e d a b c b b b c b a b b b a c a c d aaabaaababbbabbabbbecabbbbbcbea Mr Devidas Bangale 85 c e a c c e a a e b b a d a a b a c c d c a a a c d a c aaabaabaaaaccadeacabaadaca Mrs Lakshmi jamalkar 86 b c a d b b b b a a b b d a b b b a ddddcbaacaabbbabbbbbbddbcababbbbdbbb Mr Chandrakant Chondhe 87 c d a b c e b a b b b a e b c b b b b a b a c a b d aaaabaaabaabcaacdbbbbbaaebcb Mr Manohar Jadhav 88 d c a c d c a b a a b b c a a b a c c c c a e b a e b a b b b b a a b b b b a b a d a a a c a a a b c a d a Mr Mulla Mohhmad 89 a e b a a d b b b b b a c b a b b a a c a d e a b aaababaaabaabdccacbbaabaacaab Mr Sahebrao Patil 90 c c a c c e a a a a b b b a b b b b c b c a c b c d d c b b a b a b b b b a b a e c d a a b b a b b b b c a Mr Manoj Gosavi 91 e c c d e b a b b b b a e b c a b c d a d d e a a d aaaaabaaaaabcccbdbacabaaeaea Mr DevramMahajan 92 c d a b c c b a a b b b e a a b a d b a b a a b a e ddbbbaabbbbbaadccabdaabbeaca Smt Sunderidevi Sharma 93 e b a e e b a b b b b a b b c b b d a b a a c a c aaababbaaaaabdaeecbadbbaabbea Mrs Shobha Dhume 94 c e c a c e a a a a b b c a b b a d a c a a d a bdbaaababbbbaaabecdaadaabbcaca Mr Nitin Tonde 95 e a a b e d b b b b b a c a a b b d b c b a a b aaaabbabaaabbbbabeabbdbbaacbea Mr sanjay Chavan 96 e c b d e e a a a b b a b a b b b d dbddcabccdaabaaabbabcacbaaadaababaea Mrs Komal Pawar 97 c a a d c b b b b a b b a a a b a d d a d a e aaaaababbababbaacdcabbdabbbaaca Mr Nitin Tode 98 a a a c a e a a a b b a e b a b b b c a c a a bbdbdabaaaabbabedaacaabaaaaeaaa Mrs Reena Kulkarni 99 e e c b e c b b b a b b b a b b a c bbbacacaaababbabaabbdaaedbbcbbabbbea Mr Chavan Sanjay 100 e d a a e e a a a a b a b b c b b a a b a a e a b b c c b a a b aaabababeeeaaaaababaea Mr Sant Vijay 101 a d b c a e a b b a b b e a a b b b c a c a c b aaaabbbaaabaabbcbacbabbaabebaa Mrs Manjiri Ghate 102 e e a a e c b a c a b a a a b b a c a a a c d a c e b d aaabaaabbacdcbdcbcabbaaaea Mr Vikas Davre 103 e b a c e d b b e b b b b a a b b a c b c a a b aaaaabbabbbaabecdbeebabaabbbea Mr Gorakh Kharade 104 e b a b e d a a c a b a c a c b b b b c b a c a a d c e a a b b a a b b b b e d d b c c a b a b b a c a e a Mr madhukar bairagi 105 a e b d a e b b a b b b c b a b b c d c d a d b c e a c a b a a bbbaabdacadabcbaabcbab Mr Amrut Bambawale 106 e d a c e a a b b a b a b a b b a d c b c aaaaabdaaabaabbbbabdeabadbbaabbea Mrs Pramila Joshi 107 a e b d a c a a a b b b d b a b b d dddacbacaeabaaabbaaaddbaeaadbaabdbaa Mr Ratan Chakarbhate 108 e d a c e a b b b a b a b a c b a d c b c a d a c e d e a a b b a a b a a b e c c b a bbdbbbabbeb Mr Brijkumar Prasad 109 c e a a c c a b a b a b a b a b b a a a a c aaaeccaabbaabbaadadccaaaaaabaaca Mrs Bhamabai Ingawale 110 a c c b a d a b b b b a b a b b b a bbbacbbaadbbbaabbaabebcadbaaabbabaaa Mr Dnyandeo Wagh 111 e e a d e c b a a b a b a b a b a e d a d a e a c a b e b a a b aaabbbbabeeabebaababeb Mr Prakash Phad 112 c c b c c b a b b a b a b a b b b a c b c c a a a c a c a a b a bbbaabcaccabaaabaabaca Mrs Shubhangi Chitte 113 b d a d b e a b a b b b d a e b a a dddacbadedbbbbaaababdcdbaaaaaaabdaba Mr Pankaj sharma 114 c e a b c d a b b b a a c b e b b d b c b c c a a e a e b aaaaababbdeaccbadbbbacbca Mr samir Alurkar 115 e c c c e c b b a a b a c a b b b e c c c a d a d a bdbabbaaababaaeedabeaaaacaeb Mrs Anuradha Khaladkar 116 c d a a c b a b b b b b a b c b a a aaaaabacacabaaabbabbdbbcabaabbababca Smt Shaydiya Sheikh 117 a b c c a b a a a a a a c a a b b d cccccabacdbabaaaabaaeacaaaadaaaacaaa Smt hirabai Borade 118 e c b a e c b b b a b b c a b b b e a c a a e b c c a c b b a bbbbbbbdadbbbbeabbbcaeb Mr ramchandra Pingat 119 c e c b c d b a a a b a b a a b b e bbbaaababcbabaaabbaaececcabeaaaabacb Mrs Snehal Dhumal 120 b c b c b e a b b a b b d a a b a b c d c d c bddadbabbbbababbeabdbabbbbbdbba Mr shekhar Vilas 121 c a b d c a b a e a b a d b c b b d dddadaaaaebaabaabbbbcabcaebdaaaadacb Mrs Anita Kulkarni 122 e c b c e b a b e a b b b a b b a b c b c a a b b c b c b aaabbabaadbcedeabbbabbbea Mrs Shubhangi Sabasangi 123 a e b a a c a b e b b a c b a b b e a c a a c a a a c e aaababbbbbdedaaeaeaaaacaaa Mrs Kusum Ghume 124 c c a d c a b a d b b b c a a b b e d c d aaadcbebaaabbbbaadeaccdbebbbbcbcb Mr sambhaji darekar 125 a c b b a b a b e a b a b b a b a d b b b c e a c a e c b a a b aaabbbaedaaeadaaaabaaa Mr Dinesh Aher 126 c d a a c e a a c b b b a a a b b b aaaacabdaeaaabababaadcccacabbbbbabca Mrs Shakuntala davane 127 e d a e e c a b e a a a a b e b a e a a a c c b b c c c b aaaaabbbbbdbeceaebaaaabea Mrs kavita Dede 128 c e b b c d a a c a b b b a b b b d bbbaeaacaeaaabbbabbacaccacadbbabbbca Mr Amit Adwani 129 b d a e b a a b e b b a b a a b b c a b a a e a ddbdaaaaaabbbbdbdbaeacbbaabbba Mrs Rekha Jamkhande 130 e c b d e b a a c b a b d bbbaedddccbaaadababababbbeecbccaebbbbdbea Mrs jayashree waghmare 131 c b a b c c a b e a b a a a a b b c b a b a e a d d c d aaaaaabbbaecbcaeacbbaaabca Mr gopal Jeshwani 132 b d a e b e a a c b b b b b a b b e a b a a e a c c a c aaabbbabbbdacbbcaebbbbbbba Mr Navnath Ingole 133 b b b a b a b b d a b a c a b b b c a c a c c b a d c d a b aaaababbeadbcdbcbbbacbba Mr Madhav Sule 134 e e a d e c b a e b b a c a a b a e d c d aaaadacaaababababeadeaebeabbacaea Mr Arvind salunkhe 135 e e b d e a a b c b b b b a b b b c dbdaeaccbdaaababaabadbbebcacabbbbaea Mr Ramesh Patil 136 a d a a a b b a d b b a a b a b a c a a a c c a d d a a b aaabbbbabeccacdbcbbaaabaa Mr Biswant Roy 137 e e b c e e a b e b b b b a b b b c c b c a e b d b c dbbababaaaaeedeaeacabbbbaea Mr Dipak Dabhade 138 b e a e b e a a c a b a d b a b b c a d aaaaadbcbabaaabbabceabbcacaaaadaba Mr Dilip Mahajan 139 e b a d e c b b c b a a b a a b a c d b d c c a b c ddbabbbbaaabdcbebcbcbbbabbea Mr Shankar Dhargalkar 140 e d b a e e a a d b b a d a b b a b a d a a e b a d c c a a b aaabbbbdabebdabaaaadaea Mr Jaywardhan Deshpande 141 b e a b b e a b e b a b b aaaacbbbaeadddbbaababaaabaadbdeacbbabbbba Mr Shankar Varekar 142 c e a d c b b a d a b a c a a b b b d c d a e b c b b c b a b b a a b a a b d a d c a dbbaaaacacb Mr Manik Pardesi 143 e e b e e c a b c b b a c a b b a c a c a e c a a d c d a a b aaaababccabacacabbacaea Mr Yoganathan 144 e e a d e e b b e b b a c a a b b c d c d a e b b c d a b b a b a a b a a a e a e e d e a c a a a a c a e a Mr Parshuram sagare 145 b d a b b b a a c b b b c b a b a b b c b aaaacccaabaababbbeacbbcabbbbbcbba Mr ramesh Bhagwat 146 e e c e e c a b e b b a d a a b b c a d a c e bbdbcbaabaabaabeedeceacaaaadaea Mr sanjay Shelke 147 e e a d e e a b c b a a e bbbacdadacacbebaabbababbbdadeacacbbaaebea Mr Rajendra Santule 148 e b c e e b b a d b b a b a a b b c a b a c e a a d b c b a a b aaaaabdccebdacaaaabaea Mr Lakhan Yadav 149 e d a d e c a b e b b b d b a b b c dddadbacddbabaabbbbacedeaeacbbbbdbea Mr Dhondiba Mankar 150 b e a b b e a b c b b a d a a b a c bdbacacdccbabbaaaaabdaabbcacaaaadaba PRANA : SOME IMPORTANT RELATIONSHIPS Shira Shira

Urah Hridaya Kantha Kantha

Mukha Basti Ojas Nasika Shukra SITES SITES Mutual Rakta Interdependence Guda Nabhi Mamsa PRANA SUBTLE Jivhabandhan HridayaHridaya Dharana Dharana VAYU PRANA PRANA Vyayamashakti ≈ Buddhi Dharana Cardiopulmonary efficacy

Indriya Dharana FUNCTIONS PRANA ≈ BALA Immunity Avalambana of 12 Prana Manasa Bala Dhamani Dharana Avalambana Prerana Agni

Soma

Shthivana, Kshavathu, Udgara Vayu For clearing resp. & gastric passage MANAS 12 PRANA (Sushruta) Satva Raja Annapravesha Tamas  Entry of food in stomach  Entry of micronutrients in different body sites MAHASROTAS / AGNI  Receptor mechanism ??? Panchendriya  Dilatation of different body channels (Mulasthana of Pranavaha) Bhutatma