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|title=Raktapitta Nidana

|title=Raktapitta Nidana

|titlemode=append

|titlemode=append

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

|keywords=Etio-pathogenesis of raktapitta, bleeding disorders, epistaxis, hemorrhage, hematemesis, rectal bleeding, Ayurveda, Indian system of medicine, charak samhita.

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

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

|image=http://www.carakasamhitaonline.com/mediawiki-1.32.1/resources/assets/ogimgs.jpg

|image=http://www.carakasamhitaonline.com/resources/assets/ogimgs.jpg

|image_alt=carak samhita

|image_alt=carak samhita

|type=article

|type=article

<big>''' Nidana Sthana Chapter 2. Diagnosis and etiopathogenesis of Bleeding Disorders '''</big>

<big>''' Nidana Sthana Chapter 2. Diagnosis and etiopathogenesis of Bleeding Disorders '''</big>

{{Infobox

{{Infobox

|title = Raktapitta Nidana

|title = Raktapitta Nidana

|label4 = Other Sections

|label4 = Other Sections

|data4 = [[Sutra Sthana]], [[Vimana Sthana]],  [[Sharira Sthana]],  [[Indriya Sthana]], [[Chikitsa Sthana]], [[Kalpa Sthana]], [[Siddhi Sthana]]

|data4 = [[Sutra Sthana]], [[Vimana Sthana]],  [[Sharira Sthana]],  [[Indriya Sthana]], [[Chikitsa Sthana]], [[Kalpa Sthana]], [[Siddhi Sthana]]

== Introduction ==

== Introduction ==

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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''.  

The second chapter of the [[Nidana Sthana]] deals with disorders of  [[Rakta dhatu|rakta]] [[dhatu]], just as the previous chapter on [[jwara]] focused on the [[Rasa dhatu|rasa]] [[dhatu]]. [[Pitta dosha|Pitta]] is the primary cause of [[jwara]] resulting in elevated temperature. This can further lead to [[raktapitta]]. Thus it can be said that [[jwara]] is a cause of [[raktapitta]], and an aggravated [[Pitta dosha|pitta]] is the cause of both [[jwara]] and [[raktapitta]].  

Bleeding disorders also include conditions where bleeding is not apparent. Hemorrhagic strokes, vessel diseases, and heart attacks cause internal bleeding and do not erupt through the skin or orifices. These are typically due to vascular and other events and not caused due to ''raktapitta''. These disorders should be classified under ''avarana'' and ''shiragata vata''.

Bleeding disorders also include conditions where bleeding is not apparent. Hemorrhagic strokes, vessel diseases, and heart attacks cause internal bleeding and do not erupt through the skin or orifices. These are typically due to vascular and other events and not caused due to [[raktapitta]]. These disorders should be classified under [[avarana]] and disorders of [[vata dosha]] affecting vessels (siragata vata).

''Raktapitta'' manifests through two broadly divided routes that correlate with the flow of ''dosha'' energies in the body: the upper tract and the lower tract. The upper tract includes the orifices of eyes, ear, nose, and mouth/throat and is the route taken by the flow of blood when the person has an abundance of body ''kapha'' besides ''rakta'' and ''pitta''. When there is an abundance of body ''vata'' with an interplay of ''rakta'' and ''pitta'', ''raktapitta'' manifests through the lower tract using urine via hematuria and feces via occult blood. When bleeding manifests through both the routes, it indicates the involvement of both the ''doshas, vata'' and ''kapha''.  

[[Raktapitta]] manifests through two broadly divided routes that correlate with the flow of [[dosha]] energies in the body: the upper tract and the lower tract. The upper tract includes the orifices of eyes, ear, nose, and mouth/throat. It is the route taken by the flow of blood when the person has an abundance of [[Kapha dosha|kapha]] besides [[Rakta dhatu|rakta]] and [[Pitta dosha|pitta]]. When there is an abundance of body [[Vata dosha|vata]] with an interplay of [[Rakta dhatu|rakta]] and [[Pitta dosha|pitta]], [[raktapitta]] manifests through the lower tract as in hematuria and per rectal bleeding. When bleeding manifests through both the routes, it indicates the involvement of both the [[dosha]], [[Vata dosha|vata]] and [[Kapha dosha|kapha]].  

''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.

[[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. Prompt preventive action is advocated to avoid progression to incurable stage.

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==Sanskrit Text, Transliteration and English Translation==

==Sanskrit Text, Transliteration and English Translation==

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

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

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

=== Synonym of [[raktapitta]] ===

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

We shall also expound how [[Pitta dosha]] gets the term 'Lohitapitta'. [3]  

=== Etiopathogenesis ===

=== Etiopathogenesis ===

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यदा  जन्तुर्यवकोद्दालककोरदूषप्रायाण्यन्नानि भुङ्क्ते, भृशोष्णतीक्ष्णमपि चान्यदन्नजातं  निष्पावमाषकुलत्थसूपक्षारोपसंहितं, दधिदधिमण्डोदश्वित्कट्वराम्लकाञ्जिकोपसेकं  वा, वाराहमाहिषाविकमात्स्यगव्यपिशितं,  पिण्याकपिण्डालुशुष्कशाकोपहितं, मूलकसर्षपलशुन-करञ्ज-शिग्रुमधुशिग्रु(खडयूष) भूस्तृणसुमुखसुरसकुठेरकगण्डीरकालमालकपर्णासक्षवकफ-णिज्झ-कोपदंशं, सुरासौवीरतुषोदकमैरेयमेदकमधूलकशुक्तकुवलबदराम्लप्रायानुपानं वा,  पिष्टान्नोत्तरभूयिष्ठम्; उष्णाभितप्तो  वाऽतिमात्रमतिवेलं  वाऽऽमं  पयः पिबति, पयसा  समश्नाति  रौहिणीकं काणकपोतं  वा  सर्षपतैलक्षारसिद्धं, कुलत्थपिण्याकजाम्बवलकुचपक्वैः शौक्तिकैर्वा  सह  क्षीरं  बत्युष्णाभितप्तः तस्यैवमाचरतः पित्तं  प्रकोपमापद्यते,  लोहितं  च स्वप्रमाणमतिवर्तते तस्मिन्  प्रमाणातिवृत्ते  पित्तं  प्रकुपितं  शरीरमनुसर्पद्यदेव यकृत्प्लीहप्रभवाणां  लोहितवहानां  च  स्रोतसां  लोहिताभिष्यन्दगुरूणि मुखान्यासाद्य  प्रतिरुन्ध्यात् तदेव लोहितं  दूषयति||४||

यदा  जन्तुर्यवकोद्दालककोरदूषप्रायाण्यन्नानि भुङ्क्ते, भृशोष्णतीक्ष्णमपि चान्यदन्नजातं  निष्पावमाषकुलत्थसूपक्षारोपसंहितं, दधिदधिमण्डोदश्वित्कट्वराम्लकाञ्जिकोपसेकं  वा, वाराहमाहिषाविकमात्स्यगव्यपिशितं,  पिण्याकपिण्डालुशुष्कशाकोपहितं, मूलकसर्षपलशुनकरञ्जशिग्रुमधुशिग्रु(खडयूष) भूस्तृणसुमुखसुरसकुठेरकगण्डीरकालमालकपर्णासक्षवकफणिज्झकोपदंशं, सुरासौवीरतुषोदकमैरेयमेदकमधूलकशुक्तकुवलबदराम्लप्रायानुपानं वा,  पिष्टान्नोत्तरभूयिष्ठम्; उष्णाभितप्तो  वाऽतिमात्रमतिवेलं  वाऽऽमं  पयः पिबति, पयसा  समश्नाति  रौहिणीकं काणकपोतं  वा  सर्षपतैलक्षारसिद्धं, कुलत्थपिण्याकजाम्बवलकुचपक्वैः शौक्तिकैर्वा  सह  क्षीरं  बत्युष्णाभितप्तः तस्यैवमाचरतः पित्तं  प्रकोपमापद्यते,  लोहितं  च स्वप्रमाणमतिवर्तते तस्मिन्  प्रमाणातिवृत्ते  पित्तं  प्रकुपितं  शरीरमनुसर्पद्यदेव यकृत्प्लीहप्रभवाणां  लोहितवहानां  च  स्रोतसां  लोहिताभिष्यन्दगुरूणि मुखान्यासाद्य  प्रतिरुन्ध्यात् तदेव लोहितं  दूषयति||४||

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When a person consumes a diet or food consisting mostly of:

When a person consumes a diet or food mainly of:

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*Grains such as ''yavaka, uddalaka,'' and ''koradusha'', in excess quantities, along with other food items that are ''ushna'' (hot in potency) and ''tikshna'' ( sharply acting) such as  legumes of ''nishpaava'', black gram, horse gram and alkali, or with curd, whey, buttermilk, sour buttermilk or sour gruel

*Grains such as barley (yavaka), Kodo millet or [https://en.wikipedia.org/wiki/Paspalum_scrobiculatum Paspalum scrobiculatum (uddalaka)], and [http://www.agrisources.com/herbs/paspalumscrobiculatum.html Ditch Millet (koradusha)], in excess quantities, with other food items that are hot (ushna) and sharply acting (tikshna) such as  legumes of Dolichos lablab Linn. (nishpaava), black gram (masha), horse gram (kulaththa) and alkali (kshara) , or with curd, whey, buttermilk, sour buttermilk or sour gruel

*Meat of pig, buffalo, sheep, fish and cow,

*Meat of pig, buffalo, sheep, fish and cow

*Vegetables of oil cake, ''pindalu'' (a tuber) and dried potherbs

*Vegetables of oil cake (pinyaka), pindalu (a tuber) and dried potherbs

*''Upadamsha'' (chutney or salad) of radish, mustard, garlic, ''karanja, shigru, madhu shigru, kharabusa, bhustruna, sumukha, surasa, kutheraka, gandira, kalamala, parnasa, kshavaka'' and ''phanijzaka'' 

*Upadamsha (chutney or salad) of radish (mulaka), mustard (sarshapa), garlic (lashuna), fruits of Indian beech tree (Pongamia Glabra) (karanja), drumsticks (Moringa oleifera)  (shigru), its sweet variety (madhu shigru) , muskmelon (kharabusa), lemongrass (bhustruna), sumukha (Ocimum gratissimum L.), surasa (Ocimum sanctum L.), kutheraka (Ocimum basilicum L.), gandeera (Coleus barbatus (Andr.) Benth.) , kalamalaka (basil Ocimum tenuiflorum), parnasa (Ocimum basilicum L.), kshavaka (Brassica nigra (L.) Koch.) and phanijzaka (Origanum majorana L.)

*Drink of ''sura'' (wine), ''sauvira, tushodaka'' (types of vinegar), ''maireya, medaka, madhulaka'' (fermented beverages), ''shukta'' (sour beverage), sour preparations of ''kuvala'' and ''badara'' (types of jujube)  

*Consumption of fermented beverages like sura (wine), sauvira (sour gruel), tushodaka (types of vinegar or fermented water of chaff of grain or corn or rice), maireya (a type of intoxicating drink), medaka (spirituous liquor used for distillation), madhulaka (arak distilled from the blossoms of the honey tree or any intoxicating drink [Madhuca longifolia -Bot.]), shukta (any sour liquor or gruel), sour preparations of kuvala (Zizyphus mauritiana Lam.) and badara (Zizyphus mauritiana Lam.) (both are types of jujube)

*Preparations of (rice) flour in excess after meals

*Preparations of (rice) flour in excess after meals

*Excessive quantities of ''pishtanna'' (triturated grains)

*Excessive quantities of pishtanna (cake or pastries or food prepared from fine flour)

*Unboiled milk in excessive quantity or frequently, especially after exposure to intense heat, or when recovering from a heat-stroke

*Frequent and/or excess consumption of raw milk, especially after being afflicted by intense heat, or when recovering from a heat-stroke

*''Rohini'' (vegetable) along with milk  

*Eating Rohini vegetable (Myrica nagi THUNB.) with milk

*''Kanakapota'' (a type of pigeon) cooked with mustard oil and alkali

*Meat of Kanakapota (a type of pigeon) cooked with mustard oil and alkali

*Milk along with sour beverages cooked with horse gram, oil cake, fruits or ''jambu'' and ''lakucha'', when taken after exposure to intense heat.

*Consumption of milk with sour beverages, or food cooked with horse gram (kulattha), oil cake (pinyaka), fruits of jambu (Syzygium cumini (L.) Skeels) and lakucha (Artocarpus lakoocha Roxb.) after being afflicted with intense heat

With such food articles, a person’s ''pitta'' gets vitiated and the quantity of blood in his body exceeds its normal quantity. Along with the increased quantity of vitiated blood in the system, vitiated ''pitta'' gets into the circulation and reaches ''raktavaha srotas'' and its organs like liver and spleen. Due to ''abhishyandi'' and guru qualities of ''rakta'', obstructions in the channels occur leading to morbidity in ''rakta''. [4]

With such food articles, a person’s [[pitta dosha]] is vitiated and the quantity of blood in his body exceeds its normal limits. Along with the increased quantity of vitiated blood in the system, vitiated [[pitta dosha]] gets into the circulation. It reaches the channels of tranformation of blood (raktavaha srotas) originating from organs like liver and spleen. Due to excess discharge or fluidity (abhishyandi) and heaviness (guru), the congestion in the channels occur. This leads to morbidity in [[rakta dhatu]]. [4]

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संसर्गाल्लोहितप्रदूषणाल्लोहितगन्धवर्णानुविधानाच्च पित्तं  लोहितपित्तमित्याचक्षते||५||

संसर्गाल्लोहितप्रदूषणाल्लोहितगन्धवर्णानुविधानाच्च पित्तं  लोहितपित्तमित्याचक्षते||५||

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

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

=== Prodromal symptoms ===

=== 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]

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]

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=== Complications ===  

=== Complications ===  

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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]

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 ===

=== 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)

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'' ===

=== 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]

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

=== General principles of management ===

=== General principles of management ===

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The disease is acute in nature and becomes critical very quickly, spreading like bush fire. Hence its treatment should be done immediately with saturating or de-saturating soft, sweet, cold, bitter and astringent diet and pastes, baths, emesis etc. after due consideration of dose, place and time. [11]

The disease is acute in nature and becomes critical very quickly, by spreading like bush fire. Hence its treatment should be done immediately with saturating or de-saturating soft, sweet, cold, bitter and astringent diet and pastes, baths, emesis etc. after due consideration of dose, place and time. [11]

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भवन्ति  चात्र- साध्यं लोहितपित्तं तद्यदूर्ध्वं प्रतिपद्यते|  

भवन्ति  चात्र-  

 

साध्यं लोहितपित्तं तद्यदूर्ध्वं प्रतिपद्यते|  

विरेचनस्य योगित्वाद्बहुत्वाद्भेषजस्य  च||१२||

विरेचनस्य योगित्वाद्बहुत्वाद्भेषजस्य  च||१२||

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The “upward” variety of ''raktapitta'' is curable because of applicability of purgation and abundance of useful drugs. Purgation is the best remedy for alleviation of ''pitta'' and ambivalence to ''kapha''. Sweet drugs are also applicable in this case. Hence, bleeding from the upper part is curable. [12-14]  

The upward variety of [[raktapitta]] is curable because of applicability of [[purgation]] and abundance of useful drugs. [[Purgation]] is the best remedy for alleviation of [[pitta]] and ambivalence to [[kapha]]. Sweet drugs are also applicable in this case. Hence, bleeding from the upper part is curable. [12-14]  

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Hemorrhage from the lower parts is decidedly palliable because emesis has limited efficacy here and effective drugs are also a few. Emesis is not so efficacious for elimination of ''pitta'' and it is also ineffective in alleviation of ''vata'' responsible for the downward flow. Moreover, astringents and bitter drugs are not applicable there. Hence hemorrhage from the lower parts is considered palliable. [15-17]   

Hemorrhage from the lower parts is decidedly palliable because [[emesis]] has limited efficacy here and effective drugs are also a few. [[Emesis]] is not so efficacious for elimination of [[pitta]] and it is also ineffective in alleviation of [[vata]] responsible for the downward flow. Moreover, astringents and bitter drugs are not applicable there. Hence hemorrhage from the lower parts is considered palliable. [15-17]   

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In cases where blood comes out from both the routes, ''raktapitta'' is incurable because no effective evacuative measure is applicable. In ''raktapitta'', elimination of ''dosha'' from the opposite route is recommended. Thus, the three types (on the basis of the routes taken by ''rakta'') of ''raktapitta'' progression (''udarka'') have been described. [18-20]

In cases where blood comes out from both the routes, [[raktapitta]] is incurable because no effective evacuative measure is applicable. In [[raktapitta]], elimination of [[dosha]] from the opposite route is recommended. Thus, the three types (on the basis of the routes of bleeding) of [[raktapitta]] progression ([[udarka]]) have been described. [18-20]

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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]

Some curable diseases do not get treated successfully (and lead to incurability) because of following factors:

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

 

 

=== Signs of incurable [[raktapitta]] ===

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Now described are types of ''raktapitta'', identified (by their physical appearance). ''Raktapitta'' which is black, blue or of rainbow color and stains clothes is incurable. Bleeding which is of excessively fetid smell, in large quantities, and which is associated with all the complications particularly in weak and emaciated patients is incurable. A patient, if sees things around him and the sky red, is certainly suffering from an incurable variant of the disease. [23-26]

Now described are types of [[raktapitta]], identified (by their physical appearance). [[Raktapitta]] is incurable if the blood is black, blue or of rainbow color and stains clothes. Bleeding with excessively fetid smell, in large quantities, and associated with all the complications, particularly in weak and emaciated patients is incurable. A patient, if sees things around him and the sky red, is certainly suffering from an incurable variant of the disease. [23-26]

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Etiology, etymology of the disease, prodroma, complications, routes, association of ''doshas'', curability (or otherwise), with reasoning – all this has been addressed in the chapter on diagnosis of ''raktapitta'' by Punarvasu who has shed off ''tamas'' and ''rajas, doshas,'' greed, conceit and pride. [28-29]

Etiology, etymology of the disease, prodromal symptoms, complications, routes, association of [[dosha]], curability (or otherwise), with reasoning – all this has been addressed in the chapter on diagnosis of [[raktapitta]] by Punarvasu who has shed off [[tamas]] and [[rajas]], [[dosha]], greed, conceit and pride. [28-29]

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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]

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

== Tattva Vimarsha (Fundamental principles) ==

== Tattva Vimarsha (Fundamental principles) ==

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*''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''.

*''[[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]]''.

*The ''amla'' (sour), ''lavana'' (salty), ''katu'' (pungent) food articles with ''ushna'' (hot potency), ''tikshna'' (sharply acting) lead to vitiation of ''pitta dosha'' and blood. This causes ''abhishyanda'' (excess discharge leading to increase in volume of fluid) and ''guru'' (heaviness) in blood. This results in obstruction of ''raktavaha srotasa'' rooted in ''yakrita''(liver)-''pleeha'' (spleen) and ''raktapitta'' (hemorrhage).   

*The ''amla'' (sour), ''lavana'' (salty), ''katu'' (pungent) food articles with ''ushna'' (hot potency), ''tikshna'' (sharply acting) lead to vitiation of ''[[pitta dosha]]'' and blood. This causes ''abhishyanda'' (excess discharge leading to increase in volume of fluid) and ''guru'' (heaviness) in blood. This results in obstruction of ''raktavaha srotasa'' rooted in ''yakrita''(liver)-''pleeha'' (spleen) and ''[[raktapitta]]'' (hemorrhage).   

*''Raktapitta'' disorders can be classified by the route of bleeding. The vitiated ''pitta'' and ''rakta'' if gets associated with vitiated ''kapha'' causes bleeding from the upper orifices in the body. While if associated with vitiated ''vata'', it leads to bleeding from the lower orifices. Vitiation of all the three ''doshas'', from the standpoint of ''raktapitta'', is considered incurable.

*''Raktapitta'' disorders can be classified by the route of bleeding. The vitiated ''[[pitta]]'' and ''[[rakta]]'' if gets associated with vitiated ''[[kapha]]'' causes bleeding from the upper orifices in the body. While if associated with vitiated ''[[vata]]'', it leads to bleeding from the lower orifices. Vitiation of all the three ''[[dosha]]s'', from the standpoint of ''raktapitta'', is considered incurable.

*Purification therapy from the opposite route is unique for the treatment of ''raktapitta''. If the bleeding is from upper orifices then purgation is done and if it is from the lower route then ''vamana'' is indicated.  

*Purification therapy from the opposite route is unique for the treatment of ''raktapitta''. If the bleeding is from upper orifices then purgation is done and if it is from the lower route then ''[[vamana]]'' is indicated.  

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

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

== Vidhi Vimarsha (Applied Inferences) ==

== 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.  

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 ''[[rakta dhatu]]''. Blood contains formed elements (RBC, WBC, platelets) which are products of ''sarakta meda'', the integral component of ''[[majja dhatu]]''. It has ''plasma'' containing minerals, vitamins, procoagulant and anticoagulant factors, enzymes, hormones, neurotransmitters, nutrients, etc., which are mostly assigned to ''[[rasa dhatu]]''. Blood also contains fats, cholesterol, free fatty acids etc., which are products of ''[[meda dhatu]]''. It contains blood proteins such as actin, myosin, myoglobin, etc. which are integral components of ''[[mamsa dhatu]]''. It also contains metabolic wastes such as urea and lactic acid etc., which are ''mala''. Therefore, ''[[rakta dhatu]]'' is a component of blood, using it as part of its material structure for its functions.  

Blood is a balanced fluid that will not cause disease on its own, since its job is to give life. ''Rakta'' is a ''dhatu'' with the functions of ''jeevana'', carriage, transformation, and the role of traveling through the arterial system, providing building blocks for creation and sustenance of the organs in the ''koshtha''. Indeed, it was ''rakta'' that helped create them in the embryonic state. Prolonged consumption of ''pitta'' provoking diet and lifestyle vitiate ''rakta''/blood. When the ''rakta''/blood is vitiated, then it becomes an incompatible substance to the body. The body tries to clear it by expelling it in the form of bleeding.  

Blood is a balanced fluid that will not cause disease on its own, since its job is to give life. ''[[Rakta]]'' is a ''[[dhatu]]'' with the functions of ''jeevana'', carriage, transformation, and the role of traveling through the arterial system, providing building blocks for creation and sustenance of the organs in the ''koshtha''. Indeed, it was ''[[rakta]]'' that helped create them in the embryonic state. Prolonged consumption of ''[[pitta]]'' provoking diet and lifestyle vitiate ''[[rakta]]''/blood. When the ''[[rakta]]''/blood is vitiated, then it becomes an incompatible substance to the body. The body tries to clear it by expelling it in the form of bleeding.  

The ''rakta'', containing this contaminated ''pitta dosha'' provoking it, becomes increased in volume, and continues to circulate through the body, disturbing and dominating over all the functions of the ''rakta'' tissue. This ''rakta-pitta'' then blocks, coats, and vitiates the blood and the organs that ''rakta'' produces and nourishes. In ''raktapitta'', the disease requires recognition early in its course to provide a person a cure, as manifestation of actual symptoms indicates end-stage.   

The ''[[rakta]]'', containing this contaminated ''[[pitta dosha]]'' provoking it, becomes increased in volume, and continues to circulate through the body, disturbing and dominating over all the functions of the ''[[rakta]]'' tissue. This ''[[rakta]]-[[pitta]]'' then blocks, coats, and vitiates the blood and the organs that ''[[rakta]]'' produces and nourishes. In ''[[raktapitta]]'', the disease requires recognition early in its course to provide a person a cure, as manifestation of actual symptoms indicates end-stage.   

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

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

Spices and herbs with high salicylate content block vitamin K and act as natural blood thinners. The food substances mentioned in the etiology are rich in salicylates.  

Spices and herbs with high salicylate content block vitamin K and act as natural blood thinners. The food substances mentioned in the etiology are rich in salicylates.  

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.

Garlic (''Rasona'') is clearly-mentioned among the etiological factors of ''[[raktapitta]]''. [Cha.Sa.[[Nidana Sthana]] 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.

=== Omega-3 Fatty Acids ===

=== 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).

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 [[Ayurveda]] in [Cha.Sa.[[Nidana Sthana]] 2/4]

=== Alcohol ===

=== 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.  

Charak describes a group of preparations containing alcohol under [[nidana]] (etiological factors) [Cha.Sa.[[Nidana Sthana]] 2/4] like sura, sauvira, shukta, badaramala. Ayurvedic classics warn against excessive use of alcohols in [[pitta]]-vitiated patients, due to their heating and drying effects. In addition, biomedical research in 1986, suggests that subclinical vitamin K deficiency occurs in alcoholics, contributing to hypo-coagulability.  

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''.

In summary, it appears that all the foods listed, either due to inherent potency ([[veerya]]) 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 [[pitta kopa]] that leads eventually, if un-intervened, to [[raktapitta]].

=== Excess heat ===

=== 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.

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.

=== Hereditary issues ===

=== 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''.

Some bleeding disorders are known as hereditary or acquired through genetic transmission. [[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 [[Ayurveda]] with the concept of ''beeja dosha'', or inheritance of ''paapam'' through cycles of ''karma''.

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.

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.

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

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

#Thrombocytopenia:

#Thrombocytopenia:

##Diminished or defective platelet production: aplastic anemia, marrow infiltration (carcinoma, leukemia, myelofibrosis, tuberculosis, etc), infections, drugs that act on platelet production (alcohol, thiazide diuretics).

##Diminished or defective platelet production: aplastic anemia, marrow infiltration (carcinoma, leukemia, myelofibrosis, tuberculosis, etc), infections, drugs that act on platelet production (alcohol, thiazide diuretics).

##Enhanced platelet destruction: idiopathic thrombocytopenic purpura, drug-induced, thrombotic thrombocytopenic purpura. ##Sequestration of platelets: hypersplenism

##Enhanced platelet destruction: idiopathic thrombocytopenic purpura, drug-induced, thrombotic thrombocytopenic purpura.  

##Sequestration of platelets: hypersplenism

#Thrombocytosis:  

#Thrombocytosis:  

##Primary: essential thrombocythemia.

##Primary: essential thrombocythemia.

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.  

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.  

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

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

#Common causes of bleeding from the mouth include:  

#Common causes of bleeding from the mouth include:  

##Tonsillar abscess

##Tonsillar abscess

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

==== 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.  

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.  

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

=== 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)

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: [Cha.Sa.[[Nidana Sthana]] 2/4]

#''Mulaka'' (Raphanus sativus Linn.), radish, Brassicaceae family  

#''Mulaka'' (Raphanus sativus Linn.), radish, Brassicaceae family  

=== Summary ===

=== 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.   

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.   

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*[[Vidhishonitiya Adhyaya]]

*[[Vidhishonitiya Adhyaya]]

*[[Raktapitta Chikitsa]]

*[[Raktapitta Chikitsa]]

== References ==

== References ==

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