A Publication of AVP Research Foundation, Coimbatore, India.

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1 ISSN Volume 35 Issue 4 April-June 2016 Ancient Science of Life Volume 35 A Publication of AVP Research Foundation, Coimbatore, India. Issue 4 April-June 2016 Pages 193-???

2 Case Report Efficacy of Nasya (nasal medication) in coma: A case study Rajkala S. Ramteke, Panchakshari D. Patil 1, Anup B. Thakar Departments of Panchakarma and 1 Pharmacology Laboratory, Institute for Post Graduate Teaching and Research in Ayurveda, Gujarat Ayurved University, Jamnagar, Gujarat, India SUMMARY For emergency conditions, Ayurveda has never been given importance in recent times. However, there are certain emergency conditions where biomedicine has limitations but, Ayurveda can provide solution. Classics have many references regarding management of acute conditions like syncope, coma, episodic conditions of bronchial asthma, epilepsy, etc., In the present study, a 61 year female patient had a two year history of hypertension and was suffering with coma. She was treated with an Ayurvedic treatment modality. Nasya (nasal medication) of Trikaṭu cūrṇa (powder) for seven days, followed by dhūmapāna (~fumigation) with saṅkhyāsthāpana (consciousness restorative) drugs for seven days was administered. The outcome of this management was appreciable, as it resulted in positive changes in Glasgow Coma Scale (GSCS) from 3 to 11. KEYWORDS: Coma, glasgow coma scale, nasal medication, Nasya, Sanyasa INTRODUCTION Ayurvedic medicines are often considered effective for treating chronic and lifestyle related diseases only and have not been thoroughly evaluated for treating acute or terminal illnesses. In one of the published case reports it has been claimed that Ayurveda is not only effective in chronic diseases, but also effective in conditions like metastatic liver diseases where other systems of medicine are not feasible. [1] Pañcakarma is one of the specialized therapeutic applications of Ayurveda. It not only cleanses the Quick Response Code: Access this article online Website: entire bodily system but is also considered as the drug delivery method to target sites. Pañcakarma has wide field of applications such as śodhana (purification), bṛhmaṇa (nourishing therapy) or śamana (palliative measures). [2] And there are some procedures of pañcakarma which have been specified for remedial purposes such as śirodhārā in insomnia. [3] Nasya (nasal medication) which is one among pañcakarmas, delivers drug to the brain, thereby acting on whole body. [4] It plays role in majority of the conditions arising due to pathologies of ūrdhvāṅga (supra clavicular region). Coma (from the Greek Koma, meaning deep sleep ) is a state of unconsciousness lasting for more than six hours, in which a person cannot be awakened; fails to respond normally to painful stimuli, light, or sound; lacks a normal sleep wake cycle; and does not initiate voluntary actions. [5] The second most common cause of coma, which makes up about 25% of comatose patients, occurs from lack of oxygen, generally resulting from cardiac arrest. [6] Twenty percent of comatose states result from the side effects of a stroke. [7] In Ayurveda sannyāsa (coma) occurs when doṣas get acutely aggravated due to the action of speech, mind and body. After entering the site of prāṇāyatana (elan vital) i.e. heart, they weaken the individual and bring about absolute unconsciousness in the patient. [8] The coma does not subside without the administration of proper medicines. [9] In the management of coma, application of nasal drops, fumigation and powders have This is an open access article distributed under the terms of the Creative Commons Attribution NonCommercial ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non commercially, as long as the author is credited and the new creations are licensed under the identical terms. For reprints contact: reprints@medknow.com DOI: / How to cite this article: Ramteke RS, Patil PD, Thakar AB. Efficacy of Nasya (nasal medication) in coma: A case study. Ancient Sci Life 2016;35: Ancient Science of Life Published by Wolters Kluwer - Medknow

3 been indicated. [10] Caraka has brought up ten drugs for restoration of consciousness. [11] For an ethically bound Ayurvedic physician, it is a truly demanding condition when physician is asked for an intervention despite the known terminal condition of the patient. Caraka gives a code of action for these conditions by saying that, if you don t intervene, one is certain to die, if you intervene however, it may be otherwise. [12] In the present case study, one such case of hypoxic coma with three score on Glasgow Coma Scale (GGCS) was managed with Ayurvedic treatment modality. It was a challenge to give medicines to the comatose patient. Considering the condition of patient, it was decided to administer smoke of medicines as dhūma nasya (nasal medication). Nasal medication with Trikaṭu powder (pradhamana nasya) is advocated in Sannyāsa cikitsā by Caraka and Vāgbhaṭa. [13,14] Hence a treatment methodology was planned accordingly in this patient. The patient reported a remarkable recovery in the form of coma reversal, regained sensorium along with increased muscle power. CASE REPORT A sixty one year old female patient in coma since , was visited by the attending physician at the patient s residence on As per patient s attendant, patient was in Intensive Care Unit (ICU), for 28 days. Patient was thereafter discharged, maintaining Ryle s tube in situ, tracheotomy, gastric tube and oxygen inhalation along with the advice to continue physiotherapy and symptomatic treatment. On the first day of visit ( ) at the patient s residence, the patient was spotted in coma condition, not responding to verbal or painful stimuli, not opening eyes and lacking in voluntary movement of muscles. Radiological investigations revealed acute infarct in right Middle Cerebral Artery (MCA) territory causing mass effect over frontal horn of right lateral ventricle and right cerebral sulci. Changes of diffuse cerebral cortical atrophy were seen in the form of prominent left sided cerebral sulci, cisterns and ventricular cisterns. The patient was also a known case of Hypertension and on medications (Tablet Aten 50 mg) for the last 2 years. Chest X ray disclosed prominent broncho vascular marking with costo phrenic angles clear. Ultrasonography (USG Abdomen) revealed normal study, ECG was also reported normal, and other laboratory parameters were within normal limits. Bearing in mind the bad prognosis and relatively insignificant impact of the contemporary interventions made upon, an Ayurvedic intervention was opted for this case running in parallel to the biomedical interventionsalready in place. An Ayurvedic intervention in the form of nasal medication with powder and smoke was administered simultaneously with biomedical therapies. Pradhamana nasya was performed with Trikaṭu cūrṇa (powder) [Table 1], being blowed into the nostril of the patient through a tube of 15 cm length (approx. 6 aṅgula), having openings at both ends. [15] This was performed for seven days. Afterwards, the patient was treated with inhalation of fumes [16] from a dhūma stick (Aṅgula) made up of with five drugs referred to as saṅkhyāsthāpna drugs (consciousness restoring drugs) [Table 2]. This procedure was followed three times in each nostril in the morning hours and continued for seven days. Vital data was recorded daily, this included readings of temperature, blood pressure, heart rate (pulse), respiratory rate, and oxygen saturation to evaluate the patient s metabolism, fluid status, heart function, vascular integrity, and tissue oxygenation. Daily assessments were done for GGCS [Table 3]. First response was noticed in the form of opening of eyes on 3 rd day after initiation of the Ayurvedic therapy. The patient was kept under close monitoring for the preceding days. Followup of the patient was maintained for a fortnight and on the last day of followup, the patient was reported to have GGCS 11 [Table 3]. Patient started opening eyes and responding to some commands given to open mouth, close eyes, move legs. Table 1: Ingredients of Trikaṭu Cūrṇa used in Pradhamana Nasya Sanskrit Common Botanical source Part used Quantity Śuṇṭhi Ginger Zingiber officinale Rosc. Rhizome Mārīca Black pepper Piper nigrum Linn. Fruit Pippali Long pepper Piper longum Linn. Fruit Table 2: Ingredients of Dhūma Nasya Sanskrit Common Botanical source Part used Quantity Vacā Sweet flag Acorus calamus Linn. Rhizome Hiṅgu Asafoetida Ferula narthex Boiss. Resin Guggulu Indian bedellium Jaṭāmāṃsī Musk root Āmalakī Indian goose berry Commiphora wightii (Arn.) Bhandari Nordostachys jaṭāmāṃsī DC. Emblica officinalis Gaertn. Oleo resin Roots Fruit pericarp Ancient Science of Life / Apr-Jun 2016 / Vol 35 / Issue 4 233

4 Table 3: Glasgow coma scale assessment of the patient before and after Nasya Parameters Assessment criteria 0 day 7 th day 14 th day Eyes open No=1 1 To pain=2 2 To speech=3 Spontaneously=4 4 Verbal response Motor response DISCUSSION None=1 1 Incomprehensible sound=2 2 Inappropriate words=3 3 Confused=4 Oriented=5 None=1 1 Extension to pain=2 2 Flexion to pain=3 Withdrawal to pain=4 4 Localized pain=5 Obey commands=6 Total 15/15 3/15 6/15 11/15 While describing Coma, Caraka states that when vāta affects the site of mind, which has already become frail it disturbs the mind and brings about unconsciousness. Similarly pitta and kapha as well disturb the mind, resulting in the unconsciousness of the individual. [17] Trikaṭu is mentioned in the management of coma and in powder form because of its tīkṣṇa (~sharp) tendency which may directly stimulate the brain. It may do so by entering through cribriform plate and act on neurotransmitters in the brain to stimulate the excitatory neural activity. Among all sensations, only smell and taste projects both to higher cortical areas and to the limbic system. This is the probable reason that certain odors and tastes can evoke strong emotional response. Olfactory receptors react to odorant stimuli in the same way as most sensory receptors react to their specific stimuli; a generator potential (depolarization) develops and triggers one or more nerve impulses. [18] Connection of nose to brain [19] can be explained anatomically and physiologically as follows on each side of the nose bundles, slender unmyelinated axons of the olfactory receptors extend through olfactory foramina in the cribriform plate. These bundles of axons are termed olfactory nerves, they terminate in paired masses of grey matter in the brain called olfactory bulb which lie inferior to frontal lobes. Axons of olfactory bulb neurons extend posteriorly and form olfactory tract which projects into a region called lateral of olfactory area which is located at inferior and medial surface of the temporal lobe. Drugs administered through powder inhalation may stimulate the limbic system region and hypothalamus. Anatomically from the lateral olfactory area, a pathway also extends to the frontal lobe directly and indirectly via thalamus. Reticular Activating System (RAS) consists of fibres that project on to the reticular formation through the thalamus to the cerebral cortex [20] as the smoke of the drugs used in our intervention has properties like subtle and pungent, it may directly stimulate the thalamus and activate RAS which provokes higher degree of consciousness in comatose patient. The same action is also elaborated by Vāgbhaṭa who claims that the drugs administered through the nose will enter the brain and pacifiy the doṣas. [21] Consciousness restoring drugs were selected due to their action through vīrya (potency). All the medicines of this group have tīkṣṇa, uṣṇa (hot), vyavāyī, vikāsī properties, which may stimulate the brain. Considering all the properties of these medicines, smoke form of these medicines was used. Drugs such as Jaṭāmāṃsī (Nordostachys jaṭāmāṃsī DC.), Vacā (Acorus calamus Linn.), Guggulu (Commiphora wightii (Arn.) Bhandari), Hiṅgu (Ferula narthrex Boiss.), Brāhmī (Bacopa monerri (L.) Pennell.) are proven brain stimulants. It may be proposed that, as the route of administration, pharmacokinetics, and pharmacodynamics were entirely different, there was no drug drug interaction between Ayurvedic and Allopathic medicines. It is the specialty of Ayurveda that without piercing the body of patient, drug delivery can be done using different means. Generally, a person who is unable to voluntarily open the eyes, does not have a sleep wake cycle, unresponsive to strong tactile (painful), or verbal stimuli and who generally scores between 3 and 8 on the GSCS is considered in coma. [22] In the present case, the outcome was appreciable as patient responded and there was improvement in score. Patient opened eyes and started responding to commands. Improvement in the condition of the patient can be appraised by the statement of patient s husband that she started crying on being scolded. This marked improvement was a result of only fourteen days pañcakarma therapy. This case report has been shared to provide evidence that consciousness can be regained in a comatose patient with Ayurvedic drugs, and Ayurveda can be the last ray of hope in circumstances where other systems of medicine have failed. Financial support and sponsorship Nil. 234 Ancient Science of Life / Apr-Jun 2016 / Vol 35 / Issue 4

5 Conflicts of interest There are no conflicts of interest. REFERENCES 1. Rastogi S, Rastogi R. Ayurvedic intervention in metastatic liver disease. J Altern Complement Med 2012;18: Paradkar HS, editor. Ashtang Hridaya of Vagbhata, Sutra Sthana; Nasyavidhi Adhyaya. Reprint Edition. Ch. 20, Ver. 1. Varanasi: Chowkhamba Krishnadas Academy; p Paradkar HS, editor. Ashtang Hridaya of Vagbhata, Sutra Sthana; Gandushadividhi Adhyaya. Reprint Edition. Ch. 22, Ver. 24. Varanasi: Chowkhamba Krishnadas Academy; p Paradkar HS, editor. Ashtang Hridaya of Vagbhata, Sutra Sthana; Nasyavidhi Adhyaya. Reprint Edition. Ch. 20, Ver. 5. Varanasi: Chowkhamba Krishnadas Academy; p Weyhenmyeye JA, Gallman EA. Rapid Review Neuroscience. 1 st ed. Philadelphia: Mosby, Elsevier; p Liversedge T, Hirsch N. Coma. Anaesth Intensive Care Med 2010;11: Busl KM, Greer DM. Hypoxic-ischemic brain injury: Pathophysiology, neuropathology and mechanisms. NeuroRehabilitation 2010;26: Acharya YT, editor. Charaka Samhita of Agnivesha, Sutra Sthana, Vidhishonita Adhyaya. Reprint Edition. Ch. 24, Ver. 44. Varanasi: 9. Acharya YT, editor. Charaka Samhita of Agnivesha, Sutra Sthana, Vidhishonita Adhyaya. Reprint Edition. Ch. 24, Ver. 42. Varanasi: 10. Acharya YT, editor. Charaka Samhita of Agnivesha, Sutra Sthana, Vidhishonita Adhyaya. Reprint Edition. Ch. 24, Ver. 46, 52. Varanasi: 11. Acharya YT, editor. Charaka Samhita of Agnivesha, Sutra Sthana, Shadvirechanshatashritiya Adhyaya. Reprint Edition. Ch 4, Ver. 18. Varanasi: Chaukhambha Orientalia; p Acharya YT, editor. Charaka Samhita of Agnivesha, Chikitsa Sthana, Udarachikitsa Adhyaya. Reprint Edition. Ch. 13, Ver Varanasi: Chaukhambha Orientalia; p Acharya YT, editor. Charaka Samhita of Agnivesha, Sutra Sthana, Yajjapurushiya Adhyaya. Reprint Edition. Ch. 25, Ver. 46. Varanasi: Chaukhambha Orientalia; p Paradkar HS, editor. Ashtanga Hridaya of Vagbhata, Chikitsa Sthana; Madatyayadi Chikitsa Adhyaya. Reprint Edition. Ch. 7, Ver Varanasi: Chowkhamba Krishnadas Academy; p Paradkar HS, editor. Ashtanga Hridaya of Vagbhata, Sutra Sthana; Nasyavidhi Adhyaya. Reprint Edition. Ch. 20, Ver. 8. Varanasi: Chowkhamba Krishnadas Academy; p Acharya YT, editor. Commentary Ayurveda Dipika of Chakrapanidatta on Charaka Samhita, Siddhi Sthana, Trimarmiya Siddhi Adhyaya. Reprint Edition. Ch. 9, Ver. 91. Varanasi: Chaukhambha Orientalia; p Acharya YT, editor. Charaka Samhita of Agnivesha, Sutra Sthana, Vidhishonita Adhyaya. Reprint Edition. Ch. 24, Ver Varanasi: Chaukhambha Orientalia; p Tortora GJ, Grabowski SR. Principles of Anatomy and Physiology. 8 th ed., Ch. 16. New York: Harper Collins College Publishers; p Acharya YT, editor. Charaka Samhita of Agnivesha, Siddhi Sthana, Trimarmiyasiddhi Adhyaya. Reprint Edition. Ch. 9, Ver. 88. Varanasi: Chaukhambha Orientalia; p Tortora GJ, Grabowski SR. Principles of Anatomy and Physiology. 8 th ed., Ch. 16. New York: Harper Collins College Publishers; p Sharma SP, editor. Ashtanga Sangraha of Vriddha Vagbhata, Sutra Sthana; Nasyavidhi Adhyaya. 1 st ed., Ch. 29, Ver. 3. Varanasi: Chowkhamba Krishnadas Academy; p University of North Carolina. Chapel Hill: University and Russ Rowlett. Glasgow Coma Scale; c2000. Available from: unc.edu/~rowlett/units/scales/glasgow.htm. [Last updated on 2001 Jul 30; Last accessed on 2014 Jul 08]. Address for correspondence: Dr. Rajkala Shankar Ramteke, Department of Panchakarma, Institute for Post Graduate Teaching and Research in Ayurveda, Gujarat Ayurved University, Jamnagar , Gujarat, India. E mail: vaidyarajkala@gmail.com Ancient Science of Life / Apr-Jun 2016 / Vol 35 / Issue 4 235

Key words: Migraine, Nasya, Mig 17, Shirahshoola, Nasal Drop, Quick Relief

Key words: Migraine, Nasya, Mig 17, Shirahshoola, Nasal Drop, Quick Relief TO EVALUATE THE FASTER ACTION OF MIG-17 NASAL DROPS IN THE MANAGEMENT OF ARDHAVABHEDAKA W.S.R. TO MIGRAINE IN COMPARISION WITH OTHER POPULAR MODERN PAINKILLERS Dr. Tushar Trivedi a, Dr. Prerak Shah b a