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Raktapitta Nidana (view source)

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|title=Raktapitta Nidana

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|keywords=Etio-pathogenesis of raktapitta, bleeding disorders, epistaxis, hemorrhage, hematemesis, rectal bleeding

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|keywords=Etio-pathogenesis of raktapitta, bleeding disorders, epistaxis, hemorrhage, hematemesis, rectal bleeding, ayurveda, charak samhita

|description=Nidana Sthana Chapter 2. Diagnosis and etiopathogenesis of Bleeding Disorders

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=== Introduction ===

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== Introduction ==

The second chapter of the [[Nidana Sthana]] focuses on ''rakta'', the second ''dhatu'', just as the first chapter on ''jwara'' focused on the first ''dhatu, rasa''. ''Pitta'' is the primary cause of ''jwara'' which causes elevated temperature, leading to ''raktapitta''. Thus it can be said that ''jwara'' is a cause of ''raktapitta'', and an aggravated ''pitta'' is the cause of both ''jwara'' and ''raktapitta''.

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''Raktapitta'' from the upper orifices is curable, while that from the lower orifices is considered palliable. Manifestation of bleeding from both the tracts is said to be incurable. Charak advocates that in order to avoid progression to this stage, prompt preventive action should be taken.

</div>

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===Sanskrit Text, Transliteration and English Translation===

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==Sanskrit Text, Transliteration and English Translation==

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</div></div>

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Now, the ~~etio-pathogenesis~~ of ~~''raktapitta'' would be explained~~. Thus, said Lord Atreya. [1-2]

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Now we shall expound the chapter "Raktapitta Nidana" (Diagnosis and etiopathogenesis of Bleeding Disorders). Thus said Lord Atreya.[1-2]

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==== Synonym of ''raktapitta'' ====

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=== Synonym of ''raktapitta'' ===

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Also explained would be the origin of ''lohitapitta'' as an alternate name for ''pitta''. [3]

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==== Etiopathogenesis ====

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=== Etiopathogenesis ===

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''Pitta'' gets the name ''lohitapitta'' because after mixing with blood it acquires the color and smell of blood. [5]

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==== Prodromal symptoms ====

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=== Prodromal symptoms ===

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The prodromal symptoms of ''raktapitta'' include aversion to food, hot eructation just after meal, belches with smell and aftertaste of sour gruel, frequent vomiting, ugliness of vomitus, hoarseness of voice, malaise, radiating burning sensation, emittance of smoke from the mouth, smell of metal, blood, or fish , mucus in the mouth, appearance of red, green or yellow spots in body parts, feces, urine, sweat, saliva, nose-secretion, excreta from mouth and ear and boils, bodyache, and frequent vision of red, blue, yellow, blackish and brilliant objects in dreams. [6]

</div>

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==== Complications ====

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=== Complications ===

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Complications (of ''raktapitta'') include debility, anorexia, indigestion, dyspnea, cough, fever, diarrhea, edema, emaciation, anemia and hoarseness of voice. [7]

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==== Disease pathways ====

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=== Disease pathways ===

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There are two routes of the manifestation of ''raktapitta'' - upwards and downwards. In persons having an abundance of ''kapha'', vitiated ''rakta'' goes up and bleeding occurs from ear, nose, eyes and mouth. In those having an excess of ''vata, rakta'' flows downwards along with ''vata'' and patients bleed through the urinary tract and rectum. Finally, in those having abundance of both ''kapha'' and ''vata'', ''rakta'' comes out from the body with both the routes and thus bleeds through all the aforesaid orifices. [8]

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==== Prognosis ====

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=== Prognosis ===

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Amongst these, that which comes out of the upper orifices is curable and is treatable by purgation due to availability of plenty of drugs for the purpose. That coming out from the lower orifices is palliable because of being amenable to emesis and availability of lesser number of drugs for the purpose. That coming out from both the routes is incurable because of non-applicability of both emesis and purgation and in want of suitable drugs. (9)

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==== Origin of ''raktapitta'' ====

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=== Origin of ''raktapitta'' ===

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Hystorically, ''raktapitta'' occured after ''jwara'' because of Rudra’s anger pervaded the human being at the time of destruction of Daksha's sacrifice. [10]

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==== General principles of management ====

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=== General principles of management ===

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Some curable diseases do not get treated successfully because of the lack of attendants and equipments, uncontrolled self and fault of the physician. If the disease is not treated, then it proceeds to incurability. If treated well, sometimes the incurable disease may become curable or palliable. [21-23]

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==== Signs of incurable ''raktapitta'' ====

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=== Signs of incurable ''raktapitta'' ===

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A patient suffering from the incurable variant should be avoided, while the one with the palliable variant should be managed with efforts and the curable one should be treated successfully with tried remedies. [27]

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==== Summary ====

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=== Summary ===

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Thus ends the second chapter on diagnosis of ''raktapitta'' in [[Nidana Sthana]] in the treatise composed by Agnivesha and redacted by Charak. [2]

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==~~= ''~~Tattva Vimarsha~~'' /~~ Fundamental ~~Principles =~~==

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== Tattva Vimarsha (Fundamental principles) ==

*''Rakta'' and ''pitta'' have a cause-and-effect relationship because of their common origin, and this fact is important in the pathogenesis and manifestation of ''raktapitta''.

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*Prognosis is based on ''dosha'', route, purification treatment, and availability of effective medicines.

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==~~= ''~~Vidhi Vimarsha'' Applied Inferences ===

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== Vidhi Vimarsha (Applied Inferences) ==

What is ''rakta''’s relationship with blood? ''Rakta'' is a ''dhatu'', or a flowing tissue that is responsible for the sustenance of life. Unlike what has been written in various commentaries or texts on ''rakta'', blood is not the same as ''raktadhatu''. Blood contains formed elements (RBC, WBC, platelets) which are products of ''sarakta meda'', the integral component of ''majjadhatu''. It has ''plasma'' containing minerals, vitamins, procoagulant and anticoagulant factors, enzymes, hormones, neurotransmitters, nutrients, etc., which are mostly assigned to ''rasadhatu''. Blood also contains fats, cholesterol, free fatty acids etc., which are products of ''medadhatu''. It contains blood proteins such as actin, myosin, myoglobin, etc. which are integral components of ''mamsadhatu''. It also contains metabolic wastes such as urea and lactic acid etc., which are ''mala''. Therefore, ''raktadhatu'' is a component of blood, using it as part of its material structure for its functions.

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Nutritional research claims on substances linked to hypo-coagulation and/or bleeding disorders

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==== Vitamin K ====

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=== Vitamin K ===

Much of the research on dietary interactions with bleeding disorders comes from the interaction of foods with warfarin. Since 1951, warfarin has been used as an anticoagulant, effectively preventing the formation of blood clots in the blood vessels and their migration elsewhere in the body respectively. warfarin reduces the availability of the reduced form of Vitamin K1, a critical molecule in the coagulation cascade, affecting blood coagulation proteins prothrombin and factor VII. Warfarin inhibits the enzyme vitamin K epoxide reductase, which recycles Vitamin K1 from its oxidized form to a ready reduced form. The net effect is that coagulation is lessened. Foods with high vitamin K1 directly supply the vitamin to the body, bypassing the inhibition of warfarin; thus they reinitiate the coagulation pathway.

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Garlic (''Rasona'') is clearly-mentioned among the etiological factors of ''raktapitta'' (C.Ni. 2/4). Garlic contains nine different naturally-occurring anti-platelet compounds. It also acts as natural antibiotic that can kill intestinal bacteria, which manufacture vitamin K.

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==== Omega-3 Fatty Acids ====

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=== Omega-3 Fatty Acids ===

Fish oil is a rich source of omega–3 fatty acids. Omega-3-fatty acids help to thin the blood. Fish may therefore be a great food for people who are at risk of blood clots but too much consumption of omega-3 can be at risk of bleeding disorders. This fact was long back observed and reported in [https://en.wikipedia.org/wiki/[[Ayurveda]] [[Ayurveda]]] in [[Charak Samhita]] (Ni.2.4).

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===~~= Alcohols =~~===

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=== Alcohol ===

Charak describes a group of preparations containing alcohol under ''nidana'' (Ni.2.4) (etiological factors): ''sura, sauvira,'' ''shukta, badaramala''. Ayurvedic classics warn against excessive use of alcohols in ''pitta''-vitiated patients, due to their heating and drying. In addition, biomedical research in 1986, suggests that subclinical vitamin K deficiency occurs in alcoholics, contributing to hypo-coagulability.

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In summary, it appears that all the foods listed, either due to inherent ''veerya'' (heat ''dosha'' transfer potential) or combinations that create difficulty to digest using the body’s own heat, will raise a level of heat in the body that aggravates ''pitta dosha'' and initiates the cascade of ''pittakopa'' that leads eventually, if un-intervened, to ''raktapitta''.

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==== Excess heat ====

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=== Excess heat ===

Among the lifestyle factors that lead down to aggravated ''pitta'' (''viharaja nidanas'') and ''raktapitta'' are excessive exercise(''vyayama''), and exposure to sunlight. Scientific evidence has now established that vigorous exercise appears to lower vitamin K levels and thus thin the blood. Sunlight increases the conversion of Vitamin D to Vitamin D3 in the skin; a recent clinical trial of a biologically active metabolite of Vitamin D3 demonstrated an unanticipated reduction of thrombosis in cancer patients. Therefore, it appears that Vitamin D3 reduces blood clotting.

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==== Hereditary issues ====

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=== Hereditary issues ===

Some bleeding disorders are known as hereditary or acquired through genetic transmission. [https://en.wikipedia.org/wiki/[[Ayurveda]] [[Ayurveda]]] seems to point to specific foods and habits that promote the manifestation of acquired bleeding disorders; one could propose an epigenetic mechanism to explain these disorders that have eventual onset. Bleeding disorders such as hemophilia that occur from birth, indeed all hereditary imperfections, are explained in [https://en.wikipedia.org/wiki/[[Ayurveda]] [[Ayurveda]]] with the concept of ''beeja dosha'', or inheritance of ''paapam'' through cycles of ''karma''.

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Some pharmaceutical medications promote bleeding disorders. These situations can be treated by avoiding the etiological factors listed in this chapter. Once bleeding begins, the disease can be treated by removing the medicine, giving the patient sources of strong healthy ''pitta dosha'', and fortifying the ''rakta'' so that organs fed by ''rakta'' can remain as healthy as possible.

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==== Pathophysiology of Bleeding/Hemorrhagic Disorders in modern medicine ====

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=== Pathophysiology of Bleeding/Hemorrhagic Disorders in modern medicine ===

Per biomedicine, bleeding disorders are a group of heterogenous conditions that occur when the blood cannot clot properly. In normal clotting, platelets stick together when prompted by a stimulus that invokes the clotting pathway to ultimately form a plug at the site of an injured blood vessel. Proteins in the blood (clotting factors) are activated when either a pathogen or an exposed cell wall signal rupture of the blood vessel. An interactive cascade then leads to the formation of a fibrin clot, which holds the platelets in place and allows repair to occur at the site of the injury while preventing blood from escaping the blood vessel. While too much clotting can create either a thrombus or embolus that may lead to a heart attack and stroke, the inability to form clots can be very dangerous as well, as excess bleeding will also interrupt the integrity of the vascular system.

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#Clot inhibition/lysis

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===== I. Hemorrhagic Disorder Classifications =====

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==== I. Hemorrhagic Disorder Classifications ====

Hemorrhagic disorders can also occur from functional abnormalities of the vascular wall and are classified as:

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#'''Other purpuras''': purpura simplex, senile purpura, mechanic purpura, paraproteinemia

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===== II. Platelet abnormalities =====

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==== II. Platelet abnormalities ====

#Thrombocytopenia:

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##Acquired: due to drugs, uremia, liver diseases, dysproteinemias

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===== III. Coagulation disorders due to coagulation factor deficiencies =====

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==== III. Coagulation disorders due to coagulation factor deficiencies ====

#Congenital: hemophilia A (F VIII deficiency), hemophilia B (F IX deficiency),factor XI deficiency (formerly hemophilia C), hypothrombinogenemia, hypofibrinogenemia, von Willebrand’s disease, other coagulation factors deficiency, including deficiency of activatedprotein C inhibitor structural abnormalities

#Acquired: Vitamin K deficiency, severe liver diseases, drugs (dicumarol), disseminated intravascular coagulation (DIC) etc

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===== IV. Hyperfibrinolysis =====

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==== IV. Hyperfibrinolysis ====

#Primary: Congenital deficiency of α2 antiplasmin, clinical use of urokinase, liver diseases, liberation of tissue plasminogen activator into the circulation

#Secondary: DIC

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==== Causes of Bleeding ====

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=== Causes of Bleeding ===

When normal hemostatic mechanisms fail, major hemorrhage may follow minor trauma or may appear to arise spontaneously. Biomedicine observes spontaneous bleeding primarily from either the rectum or from the naso-pharyngeal cavity.

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===== A.Causes of bleeding from the mouth =====

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==== A.Causes of bleeding from the mouth ====

#Common causes of bleeding from the mouth include:

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##Tonsillar abscess

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===== B.Causes of Rectal Bleeding =====

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==== B.Causes of Rectal Bleeding ====

Rectal bleeding, known medically as hematochezia, refers to the passage of red blood through the anus, often mixed with stool and/or blood clots. Rectal bleeding occurs from the tissues adjoining the anus. Blood in the stool does not always originate from the rectum but can come from any part of the gastro-intestinal tract. In fact, the color of the blood in the stool signifies its origin and could be red, maroon, brown, or black. The blood may also be invisible to the naked eye and only appear in the stool under microscopic investigation (thus it is called occult blood). When the blood passes through the zone of digestion in the duodenum, enzymes denature the hemoglobin changing its color from red to brown. When the blood passes through both the stomach’s intense acidic environment into the duodenum’s alkaline enzymes, the denaturing process renders it black by the time it exits from the rectum. Some of the common causes of rectal bleeding include anal fissure, hemorrhoids, diverticulosis, colon cancer and polyps, post-polypectomy, angiodysplasias, colitis, proctitis, and Meckel's diverticula. Rectal bleeding originating in the colon generally appears red in color. The origin of rectal bleeding is determined by history and physical examination, including tests such as anoscopy, flexible sigmoidoscopy, colonoscopy, radionuclide scans, visceral angiograms, and blood tests. The severity of rectal bleeding, determined by the quantity of blood passed, varies widely. Most blood in the stool or rectal bleeding is mild and self-limited. Many patients report only passing a few drops of fresh blood that turns the toilet water pink or observing spots of blood on toilet paper. Others may report brief passage of a spoonful or two of blood.

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Bleeding may be moderate or severe. Patients with moderate bleeding will repeatedly pass larger quantities of bright or dark red (maroon-colored) blood often mixed with stools and/or blood clots. Patients with severe bleeding may either suffer from multiple bowel movements in a day or a single bowel movement containing a large amount of blood. Moderate or severe rectal bleeding can exhibit typical symptoms of anemia - weakness, dizziness, near-fainting or fainting, signs of low blood pressure or orthostatic hypotension, or a significant drop in blood pressure when going from a sitting or lying position to a standing position. In rare cases, the bleeding may be so severe that the body exhibits symptoms of shock due to excessive loss of blood. Moderate or severe rectal bleeding must be evaluated and treated in the hospital and may require the patient to undergo emergency hospitalization and transfusion of blood. Rectal bleeding is treated by correcting the resulting low blood volume and anemia, by determining the site and cause of blood loss, by stopping the bleeding, and by preventing relapse in bleeding.

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==== Correlation between Ayurvedic knowledge and Western medicine ====

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=== Correlation between Ayurvedic knowledge and Western medicine ===

Biomedical textbooks rarely discuss the pathophysiology of bleeding disorders in terms of diet or nutrition, unlike [[Ayurveda]]. There is, therefore, a need to research the correlation between food articles and bleeding disorders. The following food substances are etiological factors of ''raktapitta'', since these seem to act as blood thinners and can cause bleeding disorders in predisposed patients: (C.Ni. 2/4)

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Also, the pathogenesis of blood disorders do not mention why a body would be predisposed to vessel wall problems, platelet dysfunctions, or clot inhibitions. Bleeding from different orifices of the body is not correlated with pathophysiology in biomedicine. [[Ayurveda]] however discusses ''raktapitta'' as an endpoint to a series of imbalancing events, and separates the discussion of diagnosis in [[Nidana Sthana]] from the discussion of treatment in [[Chikitsa Sthana]].

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==== Summary ====

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=== Summary ===

Internal hemorrhage/hemorrhagic disorders of conventional medicine are well described in Ayurvedic texts in the form of ''raktapitta'' disorders, and the pathogenesis of ''raktapitta'' diseases forms the basis of this chapter. ''Raktapitta'' bleeding occurs through bodily orifices (mouth, rectum, urethra, nose, eye, ear, vagina, as well as hair-roots), per [[Ayurveda]]. The parallels between the description of bleeding disorders in conventional medicine and [[Ayurveda]] are quite apparent in this regard. An important aspect of the discussion on ''raktapitta'' disorders is the fact that some disorders are curable, some palliable and some are incurable – and that all these variants are dependent on ''doshic'' imbalances beyond just the ''pitta'' vitiation. It is important to note here that if proper attention is not paid, even curable disorders can soon aggravate to incurable variants. Avoidance of known causative factors is certainly one of the best measures to overcome this disease. Attempts need to be made to collect data on the effect of these factors (known to [[Ayurveda]]) and establish an empirical, evidence-based relationship between food articles (some of the primary etiological factors) and bleeding disorders.

</div>

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~~=== Glossary of Technical terms ===~~

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~~{| class="wikitable"~~

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|-

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~~| Àavika || vkfod || Relating to Sheep~~

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|-

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~~| AÉgavedanÁ || vaxosnuk || Pain in body / body ache~~

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|-

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~~| AmarÒa || ve"kZ || Non endurance / Intolerance~~

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|-

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~~| Anulomana || vuqykseu || Pushing the impurities and vata to its natural course~~

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|-

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~~| AnupÁna || vuqiku || A vehicle of the medicine. A drink taken with or after medication~~

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|-

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~~| ApatarpaÆa || viriZ.k || Desaturation~~

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|-

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~~| Arocaka || vjkspd || Anorexia~~

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|-

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~~| Àsu || vk'kq || Quick / Immediately~~

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|-

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~~| AtisÁra || vfrlkj || Diarrhoea~~

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|-

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~~| Ativelama || vfrosye~ || Repeatedly~~

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|-

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~~| AuÒadha || vkS"k/k || a kind of medicine / drug in Aurveda of natural origin~~

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|-

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~~| AvagÁha || voxkg || Deep seated, Immersed bath~~

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|-

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~~| AvipÁka || vfoikd || Non digestion of food substance to its final stage~~

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|-

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~~| BadrÁmla || cnjkEy || A sour preparation from the fruit of Zizyphus jujuba~~

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|-

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~~| BÚsténa || HkwLr`.k || Cymbopogon citratus (DC) Stapf.~~

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|-

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~~| Chardi || NfnZ || Vomiting~~

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|-

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~~| DadhimaÆda || nf/ke.M% || Watery part of Yoghurt or curd~~

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|-

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~~| GaÆdÍra || x.Mhj || Limnophila indica (Lam.) Kuntze~~

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|-

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~~| Guru || xq# || Heavy, one of the attributes of a substance, one of the potencies in drug substance.~~

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|-

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~~| JÁmbava || tkEco || Syzygium caryophyllatum (Linn.) Alston~~

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|-

−

~~| Jvara || Toj || Fever/ pyrexia~~

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|-

−

~~| KÁÆakapota || dk.kdiksra || Wild pigeon~~

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|-

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~~| KÁlamalaka || dkyekyd || Ocimum basilicum Linn.~~

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|-

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~~| KÁñjika || dkf´~td || Sour gruel~~

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|-

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~~| KaÒÁya || d"kk; || Astringent – one of the tastes perceived by tongue~~

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|-

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~~| KaÔvara || dV~oj% || Butter milk mixed with water~~

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|-

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~~| Karañja || dj´~t || Pongamia glabra Vent.~~

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|-

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~~| KatvarÁmla || dV~ojkEy || Pungent with sour~~

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|-

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~~| Kharabusa || [kjcql || Origanum majorana~~

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|-

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~~| KÒÁra || {kkj || medicinal alkali~~

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|-

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~~| KÒavaka || {kod|| Centipeda minima (Linn.) A.Br. Aschers.~~

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|-

−

~~| Kulattha || dqyRFk || Dolichos biflorus Linn.~~

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|-

−

~~| KuÔheraka || dqBsjd || Ocimum s.p~~

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|-

−

~~| Kuvala || dqoy || Zizyphus sp.~~

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|-

−

~~| LaÐuna || y'kqu || Allium sativum Linn.~~

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|-

−

~~| Lukuca || ydqp || Artocarpus lakoocha Roxb.~~

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|-

−

~~| Mada || en || Intoxicated~~

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|-

−

~~| MadhuÐigru || e/kqf'kxzq || Moringa concanersis Nimm.~~

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|-

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~~| MadhÚlaka || e/kwyd || A kind of wheat (Triticum sativum Lam.)~~

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|-

−

~~| Madhura || e/kqj || Sweet, one of the tastes perceived by tongue~~

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|-

−

~~| MÁÒa || ek"k || Phaseolus mungo Linn.~~

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|-

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~~| Medaka || esnd || One of the dietary preparation prescribed in Àyurveda~~

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|-

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~~| Médu || e`nq || Soft, one of the attributes in a food substance, one of the potencies in drug substance~~

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|-

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~~| MÚlaka || ewyd || Raphanus sativus Linn.~~

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|-

−

~~| NiÒpÁva || fu"iko || Dolichus lablab Linn.~~

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|-

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~~| PaÆÕu || ik.Mq || Anemia / Jaundice~~

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|-

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~~| ParÆÁsa || i.kkZl || Ocimum sp.~~

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|-

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~~| ParidÁha || ifjnkg || Burning around~~

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|-

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~~| Parigata || ifjxr || All around~~

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|-

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~~| PariÒeka || ifj"ksd || Pouring over / Sprinkling~~

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|-

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~~| PhaÆijjaka || Qf.k´~>d || Ocimum majurana~~

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|-

−

~~| PiÆÕalÚ || fi.Mkyq || Colocasia oleracea.~~

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|-

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~~| PiÆyÁka || fi.;kd || Liquidamber orientalis Miller.~~

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|-

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~~| Pradeha || iznsg || External application of drugs in Kalka form~~

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|-

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~~| Pratimarga || izfrekxZ || Opposite route~~

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|-

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~~| Pratirundhya || izfr:U/; || Obstructed / Hindered~~

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|-

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~~| Raja || jt || Menstrual blood~~

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|-

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~~| RauhiÆÍka || jkSfg.khd || A kind of vegetable~~

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|-

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~~| ÏiÐira || f'kf'kj || Winter season~~

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|-

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~~| Ïigru || f'kxzq || Moringa pterygosperma Gaertn.~~

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|-

−

~~| ÏoÒa || 'kks"k || Emaciation~~

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|-

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~~| Ïopha || 'kksQ || Inflammation, swelling~~

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|-

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~~| Ïukta || 'kqDr% || A kind of sour article~~

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|-

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~~| ÏuÒkaÐÁka || 'kq"d'kkd || Dry vegetables~~

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|-

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~~| SÁdhya || lk/; || Curable~~

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|-

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~~| SaÉsargÁta || lalxZ || Union / Combining~~

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|-

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~~| SaÉtarpaÆa || lariZ.k || Saturating~~

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|-

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~~| Saïsodhana || la'kks/ku || Purification~~

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|-

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~~| SarÒapa || l"kZi || Brassica compestris var. Sarson Prain~~

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|-

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~~| SauvÍra || lkSohj || A kind of Sour article~~

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|-

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~~| Srotasa || lzksrl || Channels~~

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|-

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~~| Sumukha || lqeq[k || Ocimum sp~~

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|-

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~~| SÚpa || lwi || A kind of the semi liquid dietary preparation~~

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|-

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~~| SurÁ || lqjk || A kind of Alcoholic drink~~

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|-

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~~| Surasa || lqjl || Ocimum sanctum Linn.~~

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|-

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~~| Svarabheda || LojHksn || Hoarseness of the voice~~

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|-

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~~| Tikta || frDr || Bitter, one of the tastes perceived by tongue~~

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|-

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~~| TuÒodaka || rq"kksnd || A Preparation of Kanji (sour drink) involving yava along with raw husk.~~

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|-

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~~| UdaÐvit || mnfJr~ || Whey, Diluted butter milk~~

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|-

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~~| UdagÁra || mn~xkj || Belching~~

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|-

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~~| UddÁlaka || míky% || Pasapalum scorbiclilatum Linn.~~

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|-

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~~| UpadaïÐa || mina'k || Anything which excites thirst or appetite / condiment~~

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|-

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~~| Upadrava || miæo || Complications~~

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|-

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~~| Vamana || oeu || Emesis / Vomiting~~

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|-

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~~| VÍbhatsatÁ || ohHkRlrk || Horrible~~

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|-

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~~| VidÁha || fonkg || Burning sensation~~

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|-

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~~| Virecana || fojspu || Purgation / laxative~~

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|-

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~~| Yakéta || ;Ñr || Liver~~

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|-

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~~| YÁpya || ;kI; || The controllable diseases are those that persist till the remainder of life, but can be controlled with continuous good regimen.~~

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|-

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~~| Yavaka || ;od% || A type of grain Ieum vulgare Linn.~~

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|-

−

|}

=== Related Chapters ===

*[[Vidhishonitiya Adhyaya]]

*[[Raktapitta Chikitsa]]

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=== References ===

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== References ==

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Raktapitta Nidana (view source)

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