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=== Abstract ===

=== Abstract ===

The chapter refers to vata shonita (vata rakta), a condition caused by vitiated vata dosha and rakta. As the disease is caused by predominantly vitiated vata and rakta, it follows the chapter of vatavyadhi (vatik disorder). The manifetstions of vatashonita resemble various metabolic and connective tissue diseases like gout, inflammatory polyarthritis and vasculitis. This variation in manifestation depends upon degree of vitiation of doshas and dhatu. The chapter has description of etiological factors along with types of vata shonita, purvarupa (prodromal symptoms), rupa (clinical features) of different types, rupa of dosha predominance, upadrava (complication) sadhyasadhyatwa (prognosis), treatment of different types of vatashonita, precautions during treatment as well as symptomatic treatment for relief in non-curable state of disease.

The chapter refers to ''vatashonita'' (or ''vatarakta''), a condition caused by vitiated ''vata dosha'' and ''rakta''. As the disease is caused by predominantly vitiated ''vata'' and ''rakta'', it follows [[Vatavyadhi Chikitsa]] (''vatika'' disorder). The manifestations of ''vatashonita'' resemble various metabolic and connective tissue diseases like gout, inflammatory polyarthritis and vasculitis. This variation in manifestation depends upon degree of vitiation of ''doshas'' and ''dhatu'' in each individual of unique ''prakriti''. This reflects each patient’s unique disease requiring specific personalized treatment which is unique to Ayurvedic system of management. The chapter has description of etiological factors along with types of ''vatashonita, purvarupa'' (prodromal symptoms), ''rupa'' (clinical features) of different types, ''rupa'' of ''dosha'' predominance, ''upadrava'' (complication) ,''sadhya-asadhyatva'' (prognosis), treatment of different types of ''vatashonita'', precautions during treatment as well as symptomatic treatment for relief in non-curable state of disease.

Key Words: Vata, rakta, gout, connective tissue diseases, inflammatory arthritis, polyarthritis, vasculitis.  

 

'''Keywords''': ''Vata, rakta,'' gout, connective tissue diseases, inflammatory arthritis, polyarthritis, vasculitis.  

=== Introduction ===

=== Introduction ===

After describing the chapter on various presentations of vata dominant disorders, the chapter on vata being afflicted by vitiated rakta is narrated. Vatashonita is caused by vitiated vata dosha and rakta which impede the gati (movement) of each other. It is also called as adhyaroga because it affects mainly affluent people who are not habitual to physical activity and indulged in factors responsible for vitiation of rakta.. People of pitta prakriti (pitta constitution) are prone to develop vatashonita, because sukumaratwa (delicate personality) is the characteristic feature of pitta prakriti.

After describing the chapter on various presentations of vata dominant disorders, the chapter on ''vata'' being afflicted by vitiated ''rakta'' is narrated. ''Vatashonita'' is caused by vitiated ''vata dosha'' and ''rakta'' which impede the ''gati'' (movement) of each other. It is also called as ''adhyaroga'' because it affects mainly affluent people who are not habitual to physical activity and indulged in factors responsible for vitiation of ''rakta''. People of ''pitta prakriti'' (''pitta'' constitution) are prone to develop ''vatashonita'', because ''sukumaratva'' (youthful personality) is the characteristic feature of ''pitta prakriti''.

In vata shonita there is abnormality in movemental activity (vāta dosha) due to abnormality of rakta. It is widey considered similar to gouty arthritis, however it also covers the rheumatic disorders, connective tissue disorders, inflammatory polyarthritis, vasculitis depending upon the site of vitiation.Owing to metabolic disturbances (dhatwagni vaishamya) there is overproduction of metabolites like uric acid etc.. High concentration of these metabolites in blood should be considered as raktadushti which slows the circulation of blood in capillaries and hence there is stagnation of it near the joints and dependent parts of the body. Uric acid escapes and enters the joints and other tissues from the stagnated hyperuricemic blood, and at the same time there may be reduced excretion of uric acid through kidneys, these all disturbed movemental activities are considered as vata dushti and over accumulation of metabolites because of decreased digestive capability may be considered as agniduśti. It is observed that patients suffering from vātashonita also have visamāgni (disturbed digestive capability), it is a rule that if the jatharāgni (digestive capability) is disturbed the other types of agnī (metabolism) will also be disturbed. Inflammation of joints may also occur by some other metabolites like calcium pyrophosphate crystal deposition which is also a by product and resultant of agni dushti (disturbed metabolism).

 

Further sirā (vein), dhamani(artery) etc are the āshraya (seat) for vāta and rakta. Thus due to āshraya-āshrayi (mutual abiding )sambandha (relationship) between sirā, dhamani and vāta and rakta, whenever there will be dushti of vāta and rakta it will also cause the dushti of sirā, dhamani and other mārga (path) of vāta and rakta. Also sirā and kandarā (tendons) are the upadhātu of rakta hence dushti of rakta will always cause dushti of sirā and kandharā.

In ''vatashonita'', there is abnormality in movements of ''vata dosha'' due to abnormality of ''rakta''. It is a group of inflammatory rheumatic disorders covering gouty arthritis, rheumatoid arthritis, connective tissue disorders, inflammatory polyarthritis, vasculitis depending upon the site of vitiation.  

The vasculitis syndrome, a group of disorders also needs consideration in vātarakta adhyaya. Vasculitis is a clinico-pathologic process characterized by inflammation and damage to blood vessels. The vessel lumen is usually compromised, and this is associated with ischemia of the tissues supplied by the involved vessel. A broad and heterogeneous group of syndromes may result from this process, since any type, size, and location of blood vessel may be involved. Vasculitis and its consequences may be the primary or sole manifestation of a disease; alternatively, vasculitis may be a secondary component of another primary disease. Vasculitis may be confined to a single organ, such as the skin (uttāna vātarakta), or it may simultaneously involve several organ systems (gambhira vātarakta).

 

Secondly, vasculitis alongwith thrombosis and embolism is also cause for peripheral vascular disease. Thromboangiitis obliterans (Buerger’s disease) is an inflammatory occlusive vascular disorder involving small and medium-sized arteries and veins in the distal upper and lower extremities. Disease caused due to vasospasm also has inclusion in vātarakta for eg. Raynaud’s disease.  

The vitiated factors impair ''agni'' (digestion and metabolism) at ''jatharagni'' and ''dhatvagni'' level. In ''vatarakta'', the vitiated ''vata dosha'' affects ''jatharagni'' to cause ''vishamagni'' and ''rakta dhatvagni''. This impairment leads to increase in blood and serological parameters like uric acid, C-reactive protein etc. These can be used as biomarkers for assessment of efficacy of therapy.  

Venulitis occurring in thromboangiitis obliterans, Behçet’s syndrome, and homocystinuria may also cause venous thrombosis. Thrombosis impedes the flow of blood and other nutrients thus vahan karma (transport function) of srotas sthita māruta (vata) is hampered i.e. rakta āvrita vāta takes place leading to the symptoms of vātarakta. The presence of thrombus within a superficial or deep vein and the accompanying inflammatory response in the vessel wall is termed venous thrombosis or thrombophlebitis.

 

In sirāgata vāta, Ācharya have used two words mahati sirā and tanu sirā which resembles the two conditions related to vessels viz. aneurysm and narrowing of vessels. Atheroembolism constitutes a subset of acute arterial occlusion (dhamani pratichaya). In this condition, multiple small deposits of fibrin, platelets, and cholesterol debris embolize from proximal atherosclerotic lesions or aneurysmal sites.

In process of ''rakta-dhatvagni'', ''sira'' (vessels) and ''kandara'' (tendons) are byproducts. Therefore, impairment of ''rakta-dhatvagni'' leads to involvement of deep vessels and connective tissues. This indicates ''vatarakta'' also covers diseases like vasculitis along with thrombosis and embolism, Thromboangiitis obliterans (Burger’s disease), and Raynaud’s disease.  

Thus a group of disorders explained by modern science can be included under vātashonita.

 

The chapter explains various conditions of involvement of ''dosha, dushya'' and the site of vitiation. Treatment depends upon assessment and correction of these factors causing the conditions.  

अथातो वातशोणितचिकित्सितं व्याख्यास्यामः ||१||   

अथातो वातशोणितचिकित्सितं व्याख्यास्यामः ||१||   

इति ह स्माह भगवानात्रेयः ||२||

इति ह स्माह भगवानात्रेयः ||२||

athAto vātaśonitacikitsitaM vyAkhyAsyAmaH ||1||   

athAto vātaśonitacikitsitaM vyAkhyAsyAmaH ||1||   

iti ha smAha bhagavAnAtreyaH ||2||

iti ha smAha bhagavAnAtreyaH ||2||

Now we shall expound the chapter on treatment of vata shonita. Thus said Lord Atreya. (1 – 2)

Now we shall expound the chapter on treatment of vata shonita. Thus, said Lord Atreya. (1 – 2)

हुताग्निहोत्रमासीनमृषिमध्येपुनर्वसुम् |   

हुताग्निहोत्रमासीनमृषिमध्येपुनर्वसुम् |   

पृष्टवान् गुरुमेकाग्रमग्निवेशोऽग्निवर्चसम् ||३||   

पृष्टवान् गुरुमेकाग्रमग्निवेशोऽग्निवर्चसम् ||३||   

Symptoms of uttana vata shonita are itching, burning sensation, pain, stretching sensation, piercing pain, fasciculation, feeling of constricting and the colour of skin becomes blackish, red or coppery. (20)

Symptoms of uttana vata shonita are itching, burning sensation, pain, stretching sensation, piercing pain, fasciculation, feeling of constricting and the colour of skin becomes blackish, red or coppery. (20)

Clinical features of gambhira vatarakta (deep type):

Clinical features of gambhira vatarakta (deep type):

गम्भीरे श्वयथुः स्तब्धः कठिनोऽन्तर्भृशार्तिमान्|  

गम्भीरे श्वयथुः स्तब्धः कठिनोऽन्तर्भृशार्तिमान्| श्यावस्ताम्रोऽथवा दाहतोदस्फुरणपाकवान् ||२१||   

श्यावस्ताम्रोऽथवा दाहतोदस्फुरणपाकवान् ||२१||   

रुग्विदाहान्वितोऽभीक्ष्णं वायुः सन्ध्यस्थिमज्जसु |   

रुग्विदाहान्वितोऽभीक्ष्णं वायुः सन्ध्यस्थिमज्जसु |   

छिन्दन्निव चरत्यन्तर्वक्रीकुर्वंश्च वेगवान् ||२२||   

छिन्दन्निव चरत्यन्तर्वक्रीकुर्वंश्च वेगवान् ||२२||   

After proper oleation, vatarakta paitent shall be treated with mild therapeutic purgation with unctuous substances or with dry sunstances (in case of excess oleated patient).  After purgation, the patient should be given frequent basti (enema of medicated substances) including anuvāsana basti (unctuous enema) and niruha Basti (enema made from decoction of medicinal herbs). Besides foementation, massage, ointments, food and sneha (unctuous substances) be given to the patient which do not cause burning sensation. Now listen; specific remedies. (41 – 42)

After proper oleation, vatarakta paitent shall be treated with mild therapeutic purgation with unctuous substances or with dry sunstances (in case of excess oleated patient).  After purgation, the patient should be given frequent basti (enema of medicated substances) including anuvāsana basti (unctuous enema) and niruha Basti (enema made from decoction of medicinal herbs). Besides foementation, massage, ointments, food and sneha (unctuous substances) be given to the patient which do not cause burning sensation. Now listen; specific remedies. (41 – 42)

Specific treatment:

Specific treatment:

.......................विशेषंतुनिबोधमे||४२||  

……विशेषं तु निबोध मे||४२||  

बाह्यमालेपनाभ्यङ्गपरिषेकोपनाहनैः |  

बाह्यमालेपनाभ्यङ्गपरिषेकोपनाहनैः| विरेकास्थापनस्नेहपानैर्गम्भीरमाचरेत् ||४३||   

विरेकास्थापनस्नेहपानैर्गम्भीरमाचरेत् ||४३||   

सर्पिस्तैलवसामज्जापानाभ्यञ्जनबस्तिभिः |   

सर्पिस्तैलवसामज्जापानाभ्यञ्जनबस्तिभिः |   

सुखोष्णैरुपनाहैश्च वातोत्तरमुपाचरेत् ||४४||   

सुखोष्णैरुपनाहैश्च वातोत्तरमुपाचरेत् ||४४||   

तस्मिंस्तैले चतुर्द्रोणे मधुकस्य पलेन तु |

तस्मिंस्तैले चतुर्द्रोणे मधुकस्य पलेन तु |

सिद्धं मधुककाश्मर्यसैर्वा वातरक्तनुत् ||११६||   

सिद्धं मधुककाश्मर्यसैर्वा वातरक्तनुत् ||११६||   

मधुपर्ण्याः पलं पिष्ट्वा तैलप्रस्थं चतुर्गुणे |  

मधुपर्ण्याः पलं पिष्ट्वा तैलप्रस्थं चतुर्गुणे|  

क्षीरे साध्यं शतं कृत्वा तदेवं मधुकाच्छते ||११७||   

क्षीरे साध्यं शतं कृत्वा तदेवं मधुकाच्छते ||११७||   

सिद्धं देयं त्रिदोषे [१] स्याद्वातास्रे श्वासकासनुत् |   

सिद्धं देयं त्रिदोषे [१] स्याद्वातास्रे श्वासकासनुत् |   

  tasmiMstaile caturdrōṇē madhukasya palena tu |   

  tasmiMstaile caturdrōṇē madhukasya palena tu |   

  siddhaM madhukakAshmaryasairvA vātaraktanut ||116||   

  siddhaM madhukakAshmaryasairvA vātaraktanut ||116||   

madhuparNyAH palaM piShTvA tailaprasthaM caturguNe |

madhuparNyAH palaM piShTvA tailaprasthaM caturguNe |

kShIre sādhyaM shataM kRutvA tadevaM madhukAcchate ||117||   

kShIre sādhyaM shataM kRutvA tadevaM madhukAcchate ||117||   

Pitta prdominant person leading a delicate life style is more susceptible for early progression of vatarakta.

Pitta prdominant person leading a delicate life style is more susceptible for early progression of vatarakta.

There are two types of vatashonita, 1. Uttan or superficial, located in blood vessels between skin and muscles. It manifests as itching, burning, piercing pain in skin, constricting and expanding sensation of skin, black red and coppery boils of skin.

There are two types of vatashonita, 1. Uttan or superficial, located in blood vessels between skin and muscles. It manifests as itching, burning, piercing pain in skin, constricting and expanding sensation of skin, black red and coppery boils of skin.

2. Gambhir or deep: Located in blood vessels of small joints of extremities but more in lower extremities and big toe is most affected. Manifested inflammation, hard, non shifting and painful, pulsating inflammation with coppery black color and cause of disability.

2. Gambhir or deep: Located in blood vessels of small joints of extremities but more in lower extremities and big toe is most affected. Manifested inflammation, hard, non- shifting and painful, pulsating inflammation with coppery black color and cause of disability.

Based on dosha, vatshonita is classified into four types, three of them due to one dosha and one due to three dosha, the last one is incurable.

Based on dosha, vatshonita is classified into four types, three of them due to one dosha and one due to three dosha, the last one is incurable.

Treatment is four fold with six types of blood letting, therapeutic purgation, purifying enema and palliative treatment for vata.  

Treatment is four-fold with six types of blood letting, therapeutic purgation, purifying enema and palliative treatment for vata.  

In vatarakta, rakta obstructs pathway of vata and vice-versa i.e. vata obstructing pathway of rakta. Bloodletting helps in the movement of vata.  

In vatarakta, rakta obstructs pathway of vata and vice-versa i.e. vata obstructing pathway of rakta. Bloodletting helps in the movement of vata.  

The purgation should be mild because strong purgation may cause vataprakopa.  

The purgation should be mild because strong purgation may cause vataprakopa.  

External application of unctuous substances like ghee and oil processed with herbs having cold potency, sweet and bitter tastes are effective to reduce burning sensation.  

External application of unctuous substances like ghee and oil processed with herbs having cold potency, sweet and bitter tastes are effective to reduce burning sensation.  

If vata is vitiated due to obstruction either by excessive aggravated meda or kapha, one should not apply unctuous and stouting drugs in the beginning. Instead kapha and meda subjugate with physical exercises, shodhana (purification), virechana (purgation), and intake of arishta (fermentated preparation of medicinal herbs etc.) and butter milk with abhaya.

If vata is vitiated due to obstruction either by excessive aggravated meda or kapha, one should not apply unctuous and stouting drugs in the beginning. Instead kapha and meda subjugate with physical exercises, shodhana (purification), virechana (purgation), and intake of arishta (fermentated preparation of medicinal herbs etc.) and butter milk with abhaya.

Vidhi Vimarsha:

Vidhi Vimarsha :  

Vata shonita can be referred as several metabolic and autoimmune connective tissue disorders described in the modern medical science like gout, inflammatory polyarthritis and vasculitis.

Vatarakta is a group of inflammatory rheumatic diseases. Pathogenesis of these ailments is related to aggravation of vata dosha due to vitiation of rakta dhatu. The primary sites of involvement are small joints of hands and feet.  

Pathogenesis of vatashonita.

Etiological factors:

Vitiated rakta obstructs gati of vata leading to vitiation of vata and later on vitiated vāta impedes the gati of rakta leading to further vitiation of rakta. This pathogenesis together is cause for vātarakta. In rakta āvrita vāta (covering of vata) there is either quantitative and /or qualitative increase in rakta dhātu which obstructs the gati (movement) of vāta dosha leading to āvrita vāta.

Diet: Excess intake of salty, sour and pungent foods with spices and deep fried in oil are observed to cause the disease. The soft drinks with alkalis, excess consumption of fatty substances, alcohol, aquatic animals, dried flesh are known to vitiate rakta. A study carried on 178 participants revealed that excess intake of amlarasa could be a risk factor for joint inflammation, dentine hypersensitivity, stomatitis, halitosis, heartburn and papules. Consumption of astringent, pungent, bitter, ruksha food items (grains of low nutritional values and those with dry property) vitiate vata dosha. Consumption of tikshna (sharply acting) and vidahi (which causes burning) are other factors responsible for vitiating rakta.  

Etiological agents for vitiation of rakta (Rakta dushtikara hētu)  are cause for qualitative and quantitative impairment of rakta dhatu. Excess of salty food causes quantitative increase of rakta.  Kshar causes pācana (increased digestion), daran (cracking damage) of the srotas. Sour items does pācana, mānsa vidāha  and swayathu utpādayati (produce swellings). Rakta dushti, causes inflammation. Katu rasa reduces bala (strength) and has quality to irritate the mucosal lining. Kulatha has ushna virya and amla vipaka. It causes amlapitta (hyperacidity) and thereby after vitiating pitta causes rakta dushti. Kulattha is mentioned as hētu in raktapitta where there is quantitative increase of rakta. Māsha although balya but when taken in excess quantity causes mala vridhi and is usna in nature. Tila taila, mulaka, pindālu, jalaja and ānupa mānsa by their usna guna causes raktadusti. Surā, sauviraka, sukta are usna and are raktadustikara. Virudha (incompatible), upaklinna anna (excess moisture), puti anna (putrid), divā swap (daytime sleep) lower the digestion and metabolism and have low nutritional values. Ātapa (Sun-heat) and anala sanyog(combined with fire) are external factors which directly affect the small blood vessels and are cause for local pathogenesis. Similarly abhighāta/injury also cause raktadusti as seen in case of superficial venous thrombosis after catheterization.

The dietary habits like intake of food during indigestion (ajirna), incompatible food (viruddhahar), eating food before proper digestion of previous meal (adhyashana) are causes of vitiation of vata due to improper digestion and metabolism.  

The quantitative increase of rakta causes increase in viscosity and thereby hampering the gati of vāta as seen in cases of polycythaemia rubra vera.

Psychological factors: Anger is known to vitiate pitta and secondarily rakta.  

 

Lifestyle habits: Sleeping in daytime and vigil during the night; injuries, not purifying the body (by shodhana karma); starvation, excess travelling, sporting in water, jumping, leaping, excessive walking in hot season, excessive sexual intercourse and suppression of natural urges are responsible for vitiation of vata.

Abhojanat(Starvation): Hyperuricaemia has long been known to be one of the biochemical changes accompanying starvation. Numerous workers have subsequently shown that hyperuricaemia during starvation is due to reduced uric acid clearance. Under normal physiological conditions the uric acid in glomerular filtrate is reabsorbed and that appearing in the urine is mainly derived from tubular secretion: a reduction in uric acid clearance is probably due to inhibition of tubular secretion (Gutman, Yu, and Berger, 1959). There is good evidence that a raised level of betahydroxybutyric acid in the blood can cause such inhibition and that this may be the mechanism operative in starvation and other ketotic states (Scott, McCallum, and Holloway, 1964; Goldfinger, Klinenberg, and Seegmiller, 1965). Hyperuricaemia is a feature of lactic acidosis of diabetic ketosis (Padova and Bendersky, 1962) and also of ketosis resulting from a high fat diet (Harding, Allin, Eagles, and Van Wyck, 1925; Scott and others, 1964). Snigdha, ambuja, ānūpa, māṁsa are also the hētu mentioned in ayurvedic classic for madhumeha and vātarakta.

In general, the delicate persons who are indulged in sweet and rich food substances and are not in habit of physical activities, the vata and rakta are vitiated. Those who have sedentary lifestyles with least walking are most prone to vatarakta. 2,3,

 

The above factors can cause vitiation of blood by aggravation of its tikshna (sharply acting) property and vitiation of vata dosha by aggravation of its ruksha (dry) property. The properties like sukshma (minuteness) and sara (moving) of both vata and rakta are affected to cause the disease process. Drava (fluidity) of rakta is affected leading to obstruction in free movement of vata.  

About one-third of uric acid loss is intestinal, mainly by bacterial degradation of uric acid in intestinal secretions (Sorensen, 1959). Disturbed gut microbiota is unable to cause proper bacterial degradation thus preventing the uric acid loss from the intestine leading to hyperuricemia.  .

Pathogenesis :

High uric acid levels can be reduced by minimizing the consumption of high-purine foods. These foods include organ meats, asparagus, cauliflower, dried peas and beans, mushrooms, oatmeal, spinach and wheat bran. Drinking plenty of water is recommended as it helps to flush excess uric acid from the body.

The pathogenesis involves aggravation by avarana/obstruction of movement of vata by the vitiated rakta. Therefore, the treatment is focused upon pacification of rakta to remove obstruction and pacification of vata. The pathogenesis starts from small joints of lower extremities.3 The onset of disease is acute and the vitiation of rakta occurs quickly.2 

Abhighata(trauma): Superficial venous thrombosis is associated with intravenous catheters and infusions. The risk of thrombosis is increased following trauma, such as fractures of the spine, pelvis, femur, and tibia.

Achankramanashila (indulged in sendentary lifestyle)  : Stasis of blood is one of the causes for thrombosis. Venous thrombosis may occur in >50% of patients having orthopedic surgical procedures, particularly those involving the hip or knee, and in 10–40% of patients who undergo abdominal or thoracic operations. Immobilization, regardless of the underlying disease, is a major predisposing cause of venous thrombosis.

Pain, swelling, redness, increased temperature and tenderness of small joints especially thumb or big toes. This slowly spreads to affect all joints.  

POLYCYTHAEMIA RUBRA VERA (PRV) is a myeloproliferative disorder wherein there is an abnormally high number of red blood cells and blood becomes thicker or more sludgy than normal causing blood to flow slowly and giving rise to certain symptoms and also increasing risk of thrombosis. The sludgy blood flow means oxygen cannot get to the tissues leading to various symptoms like headache, chest pain, pain in calf muscles (arti tvak mansa antarjo bhrisam), tiredness, dizziness, tinnitus, blurring of vision. Further 4 out of 10 patients release histamine causing itching and urticarial rash (sā rāga swayathu jāyante mandalānica). Complexion is a bit more ruddy than normal due to increase number of RBC. Some patients may present with bruising, epistaxis and gastrointestinal bleeding. This presentation should be understood under raktapitta. Also about 1 in 10 people with PRV develop gout wherein concept of vātarakta should be considered. This also signifies the common hētu which Acharyas have mentioned in respect to raktapitta, vātarakta and raktadusti.

Itching, burning, pricking, pulsating, breaking pain in skin

Venesection is one among the treatments for PRV which removes the extra red blood cells and makes blood less viscous so that it circulates better. Regular venesection is preferred. Acharyas have explained raktamokshana in vātarakta and treatment of raktāvritta vāta is similar to vātarakta.

Greyish, copperish discolouration of skin

Apparent erythrocytosis where RBC are more concentrated can be caused by many things such as obesity (recollect the jalaj,  ānup,  mānsa,  māsha etc are causes of sthaulya and raktadusti),  alcohol (surā sāuvira),  stress ( krodhādi), smoking (tiksna, usna dravya), less fluid, diuretics, high blood pressure, kidney disease etc. The presentation is similar to PRV.

In case of involvement of deeper tissues, swelling, hardness of affected site, discoloration, suppuration, pulsating, pricking or burning sensation can occur.  

Hyperviscosity Syndrome; it is a group of symptoms triggered by increase in the viscosity of the blood. Type of hyper viscosity syndrome vary by pathology,

Above features are observed at sites of joints, ligaments and blood vessels as per the dosha dominance in vatarakta.  

Uttana vatarakta involves twacha (skin) and mamsa (muscular tissue). Gambhira vatarakta involves all other tissues. The uttana vatarakta progresses to gambhira vatarakta in due course of time.2,3

3) Syndrome of hyperviscosity caused by rigidity of RBC often evident in sickle cell anaemia (note pinyaka, harita shaka etc have low nutritional value (Vitamin B12) and are explained as rakta dustikar hētu).

Blood viscosity is a measure of the resistance to the blood flow. This biophysical property makes it a critical determinant of friction against the vessel walls, the rate of venous return, the work required for the heart to pump blood and how much oxygen is transported to tissues and organs. These functions of the cardiovascular system are directly related to vascular resistance, preload, afterload and perfusion respectively.

Vatarakta, aamavata and sandhigata vata are three most common rheumatological clinical conditions. The clinical presentations need to be differentiated for diagnosis and designing treatment protocol.  

Phlebitis is the inflammation of vein. It most commonly occurs in superficial veins. Phlebitis often occurs in conjunction with thrombosis and is then called as thrombophlebitis. It is typically caused by local trauma (abhighata to the vein). It can also result from certain medications and drugs that irritate the veins i.e. vascular irritant (tiksna, usna, ksāra katu dravya). These causes are directly affecting the mārga or the channels/ sirā. Immune factors (vikār vighātkar bhāva) come into play at the site of injury, if they are strong enough no inflammation occurs but if there is faulty response inflammation occurs at the site of injury (kha vaigunya). Inflamed endothelium now leads to coagulopathy. Thrombus formation causes obstruction to the flow of blood leading to symptoms like localized redness and swelling (sā rāga swayathu mandala), pain or burning along the length of the vein (sā dāha arti tvak mānsa antarja bhrusam) and veins become hard and cord like (dāruntā).

Erythromelalgia: It is a rare neurovascular peripheral pain disorder (arti) in which blood vessels, usually in the lower extremity or hands are episodically blocked then become hyperemic and inflamed (rāga, swayathu). These episodes are commonly triggered by heat, pressure, mild activity, exertion, insomnia or stress. It is classified into primary and secondary. The primary type resembles the second phase of vātarakta wherein vitiated vāta dosha impedes gati of rakta and secondary erythromelagia caused by essential thrombocytosis resembles rakta āvrita vāta.

The qualitative vitiation of rakta is brought about by hētu which vitiates agni (jātharāgni, bhutāgni and dhatvāgni) and which are responsible for vitiation of srotas mula for e.g. alcoholic drinks, smoking, meat, seafood, anger etc which leads to metabolic disturbances and when it makes its seat at the level of joints it leads to gout and other crystal- associated arthropathies.

Dushya Rakta, Twak, mamsa Rasa Asthi, majja

Clinical features Pain, burning sensation, swelling, tenderness Pain, swelling, tenderness Painful movements

Before the bloodletting, the patient should be examined thoroughly to ensure whether or not he is fit for it, his bleeding time and clotting time must be determined. The patient must be given snehana (oleation) and mild swedana (sudation) before blood letting, blood should let out in small quantity at many times till dushta rakta has let out completely and shuddha rakta has started coming out. Very experienced physician can confirm that the dushta rakta has been let out. Best way for this is jalaukā (leech), blood letting is very effective when there is chronic swelling and discolouration of the part. Through bloodletting stagnated blood having high concentration of metabolites comes out, allows blood to flow rather easily from the part thus improving the condition of the patient.

Nature of pain/spread of disease pathogens  Spreads like rat poison (moderate), pulsating Like scorpion bite (severe), fleeting Pain on movement, stable

Importance of bloodletting: Physiologically, blood communicates at almost every zone of human body either directly or by indirect influences. The role and importance of rakta (blood tissue) in the genesis, manifestation and progress of various clinical conditions with respect to vātarakta is evident. Sirāvyadha is one such radical treatment especially concerned with dusta rakta nirharana (the macroscopic removal of ‘morbid blood’ from unwanted contexts or situations). Patho-physiological studies suggest that in case of a considerable blood loss (> 100 ml), the immediate haemo-dilution stimulates/ triggers a host of beneficial physiological mechanisms making the body alert and adaptive to take care of various systemic challenges present. Back up support in the form of immunologic, inflammatory and trigger factors intended for specific purposes is recruited in pathological tissues for the management of the damage. After considerable amount of bloodletting, Psycho-Neuro-Endocrinal mechanisms mediated by Hypothalamus, Pituitary, and Adrenocortic axis are triggered. Brain responds with commanding actions through efferent signals to vessel or vascular system.

Joints involved Small joints like metacarpal and metatarsal joints Big joints like knee, elbow, shoulder and sacroiliac joint. Wear and tear of excessively used joints

Reaction to sneha (oleation) mild sneha is indicated Strictly contra-indicated as pain increases after massage and oleation Indicated, pain reduces after massage and oleation

Aggravating factors in diet Hot, sour, salty, pungent Salt, sweet, heavy to digest food Bitter, pungent, light to digest food

Aggravating factors Exposure to heat, travelling Sedentary lifestyle, exertion immediately after taking food Overuse of joints

Treatment Sneha, virechana, basti with drugs of mild property, raktamokshna  Langhana, basti with drugs of sharp acting property Snehana, basti, brumhana

In Vātarakta which is a metabolic disorder of impairment of purine metabolism, serum uric acid level is high and also there is inadequate excretion i.e. nothing but hyperuricemia. Bloodletting in dorsal venous arch causes reduction in uric acid. There may be release of angiotensin hormone which has got renal and adreno-cortical stimulatory effect providing excretion of uric acid by kidneys. Erythropoietin may be activated, which in turn successfully addresses most of the circulatory / vascular related healing drifts. The dushta rakta which is shaakhashrita in acute stages are expelled readily by sirāvyadha as it is the nearest route for dosha nirharana. Shonitha Kleda is one of the pittaja nanatmaja vikara and here kleda refers to multiple intermediate metabolites, particles etc, embedded in rakta hence raktamokshana by sirāvyadha is an attempt to reduce the excessive kleda in shonitha.

Those patients with involvement of small joints of extremities resemble rheumatoid arthritis, on the other hand patients with mono-articular or oligo-articular arthritis and associated elevated uric acid resemble gout. There is a difference of opinion among ayurvedic physicians, some call vatarakta as gout and others call rheumatoid arthritis. Some ayurvedic physicians consider aamvata as rheumatoid arthritis. However, it can be observed that the patients diagnosed as rheumatoid arthritis show clinical features of vitiation of vata associated with kapha dosha. Whereas, the patients diagnosed as gouty arthritis show clinical features of vitiation of vata associated with pitta dosha. Therefore, the former case can be treated on the lines of vatarakta associated with kapha, while the latter can be treated on principles of vatarakta associated with pitta. On close observation it is noted that in aamvata there is involvement of large joins of extremities and sacroiliac joints which is consistent with rheumatoid variant or ankylosing spondylitis. Ayurvedic management depends upon correction of imbalance of dosha, dushya and prakriti of the individual and can be viewed as working through epigenetic pathway. On the other hand, modern medicine system works by antagonizing the pro-inflammatory proteins or acting through “genetic pathway”. It becomes clear that both systems achieve the objective using different ways. It can be compared to digging the tunnel from both sides. However, the direction of diagnosis and treatment needs to be clearly based upon clinical assessment of dosha dominance. The serological parameters can only be utilized for assessment of therapy. 

The condition in which blood vessels, connective tissues and tendons are involved such as vasculitis along with thrombosis and embolism, Thrombo angiitis obliterans (Burger’s disease), Raynaud’s disease are also considered under the disease vatarakta. The treatment focus on correction of rakta-dhatvagni, through which mechanisms in sira(vessels) and kandara(tendons) are corrected.

Serological investigations like Erythrocyte sedimentation rate, C-reactive protein, uric acid, quantitative and qualitative assessment of rheumatoid factor may be investigated as biomarkers.

Radiological investigations including X-rays of affected part

Ultrasound, histopathological study and angiography.  

Even more, amlata in rakta (inflammatory markers, intermediate metabolites, acidic components like uric acid) is responsible for ruk (all types of pain). The complex activities which render pathological sequence leads to permanent and hallmark pathological features like gouty arthritis. No drug or regimen is effective to dislodge these factors easily and effectively. The new ‘regional balance’ of morbidities in a disease will transiently get disturbed on to a positive plane by sirāvyadhana followed by re-launching of healing mechanisms. In general, various probable mechanisms are going to change in body by bloodletting, such as local blood supply is improved, local metabolism is improved, local drainage system is improved, fresh RBCs are produced which are active. Hepatocellular activity in particular enzyme system is improved which results in correction of purine metabolism hence regulation of Uric acid generation. Release of hormones, sympathetic nerve function etc, are triggered which directly stimulates bone marrow and immune related T-Lymphocytes.

Insomnia, permanent joint deformity, gangrene, necrosis, tumour can occur as complication of vatarakta.  

Kshira (milk) is laxative along with jīvaniya property. It has the property of pacifying vitiated vāta and pitta dosha as well as rakta. When milk is processed with medicinal herbs, mixed with ghr̥ta and introduced into lower part of intestine in the form of basti, it will produce laxation and milk protein will stimulate mucosal layer of intestine whereby there will be increased secretions towards intestines in which intermediate metabolites may come out and may be easily expelled out with enema. Importance of basti:

Due to properties like sukshmatva and saratwa of vVayu, dravatwa and saratwa of rakta they spread all over the body. The spreading is facilitated by vyana vVayu. The dosha get lodged in sandhi. In this respect the control over vVayuVayu in turn rakta is achieved by basti.

As asthidhatu (asthi sandhi) is involved in pathogenesis of vātarakta, it is to be assumed that the drug acting upon pureeshadharā kalā will certainly act on the asthidarā kalā, as kalā of both the dhatu are the same. In addition the active principles of basti dravya administered reaches up to the grahani which is related to both pittadharā kalā and majjādharā kalā. Hence holistic action of basti in terms of cleansing and nourishment of asthi dhātu, sandhi, majjā etc. and ultimately resulting in vātasamana is perceived clinically.

Prognosis considering present developments in medicine:

 

The disease with involvement of single dosha and new (diagnosed within one year) is curable. The disease with involvement of more than one dosha and chronic (more than one year) is palliable with medicines and appropriate therapies.

The rectum has a rich blood and lymph supply and drugs can cross the rectal mucosa like other lipid membranes. The unionized and lipid soluble substances are rapidly absorbed from the rectum. In the upper portion of rectum, absorption is via the upper rectal mucosa and is carried to the superior hemorrhoidal vein into portal circulation where as that which is absorbed in the lower rectum enter directly into the systemic circulation via middle and inferior hemorrhoidal vein. This systemic assent gained is helpful for generalized cleansing followed by vigour promotion.

Management of diseases (Treatment protocols)  

In the context of vātarakta chikitsā the vitiated dosha along with mala should be expelled out by the administration of sa gritha ksheerabasti. Here ksheera has pittahara, rakta prasādaka and vāta anulomana effect. The chemical reaction sequence originated in pakwāsaya by basti passes from cell-to-cell, ultimately in to the entire body. 1/3rd of Serum uric acid is excreted through the gut and the remaining 2/3rd through the kidneys generally. Basti, because of its laxative action, increases expulsion of uric acid through gut. Even more, guduchi siddha yoga basti has mutrala, uricosuric properties i.e. increases the excretion of uric acid through urine.

Principles of management: 1. Basti 2. Snehana 3. Raktamokshana

 

Therapeutic purification:

In a nut shell, high dose administration of guduchi (active alkaloid-Berberine) will act as analgesic, anti-inflammatory and exhibits corticosteroid action. Ksheera (Milk) used, reopens calcium channel and along with this saindhava lavana enhances the integrity of asthi dhatu. Mixture of madhu, saindhava, ksheera produces abhishyandhi guna which is influential in dissolving urate crystals.

Basti (therapeutic enema): Basti with herbs of ruksha (dry) property or mrudu (mild) property are used to treat both uttana (superficial) and gambhira (deep) types of vatarakta.  

 

Raktamokshana (bloodletting):  Bloodletting is prescribed as per dosha dominance in vatarakta patients. This gives better results to remove obstruction and reduce vitiation of blood.

These observations suggest that this therapy not only produces symptomatic relief but also control the disease process and may cause long lasting relief.  

Main drugs: 1. Guduchi 2. Kokilaksha 3. Suranjan  

Effect of various herbs:Research on Glycerrhiza glabra showed a significant decrease in the concentration of urea, uric acid and creatinine. This is in agreement with the reports of others (Fukai et al. 1998) as it has been reported that anti-nephritis activity of glabradin, a pyranis of lavan isolated from Glycerrhiza glabra, was evaluated after its oral administration to mice with glomerular disease by measuring urinary protein excretion, BUN, and serum creatinine level, which reduced the amount of the earlier parameters significantly. Glycyrrhizin acid exhibits anti-inflammatory activity by inhibitory glucocorticoid metabolism. (Sitohy et al 1991; Fukai et. Al.1998). Hyperuricemia is a metabolic disorder which plays an important role in the development of gout and several oxidative stress diseases such as cancer and cardiovascular diseases. Nitric oxide also has been implicated in both osteoarthritis and rheumatoid arthritis, while studies show that anti oxidant scavenge this oxidant and potentially aid in the treatment or prevention of symptoms of arthritis (Strazzullo and Puig, 2007). Further glycyrrhizin is the first plant based inhibitor of thrombin. It is found to prolong the thrombin and fibrinogen clotting time. It also increases plasma re-calcification duration. (www.florajournal.com/archives/2014/vol2issue2/PartC/23.1.pdf)

Guduchi: Tinospora cordifolia is mentioned to treat vātarakta (gouty arthritis) and daha (burning sensation). The alcoholic extract of T. cordifolia has been found to exert anti-inflammatory actions in models of acute and subacute inflammation and its mode of action appeared to resemble that of non-steroidal anti-inflammatory agent.    

Paste preparation from gr̥hadhūmō (soot), vacā, kuśtha, śatāhvā, haridrā and daru haridrā alleviates pain of vāta kapha predominant vātarakta beneficial in shoola (pain). This paste is used widely in Kerala and found to be extremely effective in the management of rheumatoid arthritis.

Each and every disease has āmavastha and nirāmavastha, this principle can be applied everywhere in āmavastha of the diseases.

Guggulu is a plant resin containing natural steroids called guggulosterons which are useful in lowering the cholesterol levels and reduces pain naturally. Guggulu is not only effective in lowering cholesterol but are natural alternative to pain killers. Guggulu Capsules are an effective natural pain relief and useful in all types of inflammation. Clinical medicines used in vatarakta:

Main drugs: 1. Guduchi 2. Kokilaksha 3. Suranjan  

Type Name Dose Time Anupana

Type Name Dose Time Anupana

Vataja Kaishora guggulu 500-1000 mg Between two meals Kokilaksha kwatha + ghee + honey

Vataja Kaishora guggulu 500-1000 mg Between two meals Kokilaksha kwatha + ghee + honey

Kaphaja Guda-bhallataka-haritaki vati 1 -3 grams Before meals two times Milk or lukewarm water

Kaphaja Guda-bhallataka-haritaki vati 1 -3 grams Before meals two times Milk or lukewarm water

Reference:

Evidence based clinical practices:  

 

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