Introduction
"A man's life may be said to be a gift of his blood pressure, just as Egypt is a gift of the Nile". So said Sir William Osler, an icon of modern medicine and the man said to be the most influential physician in history.
Sir Osler may be indeed right, as arterial pressure is essential for sustaining life, the most important factor which ensures that the circulation of blood reaches all the tissues in our body. At the same time, an elevated blood pressure can be most inimical to life, if persisting over a period of time.

The pioneers in the study of arterial pressure, Reverend Stephen Hale, who made the first blood pressure measurement on animals, and Scipione Riva Rocci, who invented the blood pressure cuff, were probably not aware of the full significance of their discoveries. It was only in the late 1950's that the medical world became aware of the importance of high blood pressure as a precursor of complications commonly attributed to "old age".

At the present day, an elevated blood pressure level is recognized as the most important public health problem in the developed countries, and essential hypertension is held responsible for more than 95% of the cases. It is common, asymptomatic, and lead to lethal complications if left untreated. The "silent killer" as it is known, is gradually becoming a problem of enormous proportions in the developing world also.

The practitioners of the allopathic system of medicine have tried to combat this malady by trying to develop drugs designed to reduce the high arterial pressure. Over the years they have been successful in developing drugs with profound blood pressure lowering capabilities, but the magnitude of the problem at the community level has remained. The reasons for this are many, including the adverse effect of drugs and relatively higher cost of treatment, but the absence of a holistic view of disease is probably the most important. As with other conditions, the inclination is to treat the "results" of disease. This ultimately proves less successful, and is also detrimental to the health of the patient.

The homoeopathic physician on the other hand, considers disease as a disturbance of the life force, made known to him only through signs and symptoms. He understands that the patient is sick prior to the localization of disease. The hypertension, like other diagnoses, is considered only as a part of the whole. The homoeopathic approach also does not have the other drawbacks seen with the allopathic system, like adverse effect of drugs and high cost of treatment. Thus it is potentially suitable to deal with the problem of essential hypertension, especially in a developing country like India.

Unfortunately there is little information regarding the management of hypertension in homoeopathic literature. Many of the classical therapeutic text books and materia medicae do not mention the condition at all. This is possibly due to the lack of awareness about hypertension during the earlier days of homoeopathy. Clinical studies on the effectiveness of homoeopathic medicines in hypertension also has been few. Off the studies published, most have tried to evaluate the action of "specific" drugs rather than use an individualized approach.

All these factors, have encouraged me to take up this study on the efficacy of homoeopathic medicines in the management of essential hypertension. It is hoped that useful information will be gained both on the entity of essential hypertension, as well as the homoeopathic approach to its management.

Survey of Literature                
Definition and classification
Blood pressure2 is a continuously distributed variable in populations, with no clear distinction between hypertensive and normotensive individuals. The distribution follows a bell shaped curve, slightly skewed to the right. The risks associated also follows the blood pressure curve, and it is not possible to identify a level of blood pressure that carries risk and one that does not. Any definition of "hypertension" is therefore arbitrary.
                             
The WHO and the International society of Hypertension has defined hypertension as "a systolic blood pressure of 140 mm Hg. or greater, or a diastolic blood pressure of 90 mm Hg. or greater in subjects who are not taking anti-hypertensive medication". This traditional level of hypertension is a pragmatic one, based on evidence4,5 of treatment benefit, balanced against side effects and cost of treatment. Indeed, hypertension can be defined as blood pressure6 levels above which treatment does more good than harm.
Various organizations have classified blood pressure into different levels of severity. The classification of WHO - ISH is given below.

Grade II (Moderate)

            Table 1. WHO - ISH classification of blood pressure

 * For adults aged 18 or older.
* When a patients systolic and diastolic blood pressure falls into different categories, the higher category should apply
+ With respect to cardiovascular risk

Hypertension: The Problem

Cardiovascular diseases7 are responsible for around 20% of all deaths worldwide. They are the principal cause of death in developed countries, accounting for about 50% of all deaths. They are also emerging as a prominent public health problem in developing countries, ranking third among the main causes, with approximately 16% of all deaths.
The most common among these diseases are hypertension, ischemic heart disease, and cerebrovascular disease. Considering3 the central role of hypertension in the pathogenesis of both coronary heart disease and stroke, it is clear that its control is one of the biggest challenges facing public health authorities and medical practitioners all over the world.
Prevalence: Global

Hypertension8 affects up to a quarter of the adult population. The prevalence depends on the age, racial composition and the criteria used to define the condition. In a white population, 20% of the adults in the age group 35 - 65 years have a diastolic blood pressure in the range 90 - 109 mm Hg, 4 - 5% have a range of 110 - 129 mm Hg, and 0.5% have blood pressure levels > 130 mm Hg. The prevalence is even higher in the non white population.

Prevalence: India
Epedemiological9 studies show a rising trend in the prevalence of hypertension in India in the last three decades. This is in contrast to with the findings reported in developed countries, which show a decrease in prevalence. Studies10 show overall prevalence in the age group 25 - 64 years as 25.6 %. This11 figure is close to 33% in the age group 45 - 65 years.

Prevalence: Kerala
Kerala has a high prevalence of hypertension, as shown by the results of a multicentric study10 among five Indian cities, where Thiruvananthapuram had the highest prevalence of hypertension with 30.7% of the population affected. The percentages are much higher in the elderly population, and in urban than in rural areas
In a study12 conducted by the hypertension study group among subjects aged = 60 years, 69% of the sample from urban areas and 55% from rural areas were found to be hypertensive. Kerala11 also has a high prevalence of other cardiovascular risk factors like obesity, smoking, lack of exercise etc., which is more marked in the urban population.

The "rule of halves"
The magnitude of the problem is compounded by the fact that hypertension remains an "iceberg" disease, with a large percentage of cases remaining undetected. In the early 1970's it became evident that only half the hypertensive subjects in developed countries were aware of the condition. About half of them were being treated with drugs, and only half of those treated were adequately treated. This came to be known as the "rule of halves", and the situation in the developing countries is likely to be far worse.

Causes of Hypertension
Traditionally, hypertension has been classified into essential2 or primary, where there is no evident cause, and secondary, where there is an evident anatomical, pathological or biochemical abnormality. But this view of essential hypertension is increasingly being challenged with the recognition of constitutional, dietary and environmental factors in its pathogenesis.
Essential5 hypertension is the commonest among the causes of hypertension, constituting up to 95% of the cases. Among the secondary causes, renal diseases account for the majority of cases. A useful classification is given below

1) Systolic hypertension with increased pulse pressure
a) With decreased compliance of aorta (arteriosclerosis)
b) With increased stroke volume
i) Aortic regurgitation
ii) Thyrotoxicosis
iii) Fever
iv) A-V fistula
v) Patent ductus arteriosus

2) Systolic and diastolic hypertension (increased peripheral vascular resistance)
a) Unknown aetiology
i) Essential hypertension
ii) Toxemia's of pregnancy
iii) Acute intermittent porphyria
b) Renal causes
i) Chronic pyelonephritis
ii) Acute or chronic glomerulonephritis
iii) Polycystic disease
iv) Renovascular stenosis or renal infarction
v) Severe renal diseases e.g. Diabetic nephropathy
vi) Renin producing tumors
c) Endocrine causes
i) Cushing's syndrome / Cushing's disease
ii) Conn's syndrome
iii) Pheochromocytoma
iv) Hypothyroidism
v) Acromegaly
d) Iatrogenic causes
i) Oral contraceptive pills
ii) ACTH & Corticosteroids
iii) Non-steroidal anti-inflammatory drugs
e) Miscellaneous causes
i) Coarctation of aorta
ii) Poisoning - lead, thallium etc
iii) Polyarteritis nodosa
iv) Increased intravascular- volume - blood transfusion, Polycythemia vera etc.
v) Increased intracranial pressure

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