Raktamokshana

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The word raktamoksha or raktamokshana literally means ‘to release blood’. It is one of the five purification procedures (panchakarma) and is important therapeutic procedure in management of disorders due to vitiation of rakta (blood) and pitta dosha.[1] Bloodletting therapy is done with specific pre-therapeutic regimen. The blood is drawn in little quantity and is not reused for any other purpose.

Contributors
Section/Chapter/topic Chikitsa / Panchakarma/ Raktamokshana
Authors Aneesh E.G., Deole Y.S.
Reviewed by Basisht G.
Affiliations Charak Samhita Research, Training and Development Centre, I.P.G.T.& R.A., Jamnagar
Correspondence email: carakasamhita@gmail.com
Date of first publication: December 26, 2020
DOI 10.47468/CSNE.2020.e01.s09.036

Synonyms

Asravisruti, shonitamokshana, raktanirharana, raktasravana, raktaharana etc.

Indications of bloodletting therapy

Bloodletting therapy (raktamoksha) is mainly indicated in diseases due to blood (rakta) and pitta dosha. This includes skin diseases, abscess, diseases pertaining to earlobes etc. [Cha.Sa.Sutra Sthana 24/11-16] [A.Hr. Sutra Sthana 27/3-5][2]

Contraindications of bloodletting therapy

Raktamoksha is contraindicated in following conditions:

  • Too emaciated patients
  • Generalized edema, anemia
  • Pregnant women [Su.Sa.Sutra Sthana.14/24][3]
  • In too cold and too hot climate [Su.Sa.Sutra Sthana.14/27][3] [Su.Sa.Sharira Sthana.8/7][3]
  • Immediately after other panchakarma therapies [A.Hr. Sutra Sthana.27/6-8][2]

Classification

Bloodletting is divided into two types

  1. With surgical instruments (sashastra)
  2. Without surgical instruments (ashastra)

Bloodletting with surgical instruments is of two types [Su.Sa.Sutra Sthana.14/25][3]

  • Puncturing (pracchana)
  • Venesection (siravyadha)

Bloodletting without surgical instruments is of four types

  • Application of leeches (jalaukavacharana)
  • Application of horn (shringaavacharana)
  • Application of gourd (alabuavacharana)
  • Application of pot like instrument (ghatiavacharana)

Nowadays, indigenous methods like using animal horns (shringaavacharana), gourd (alabuavacharana) and pot (ghati) are rarely used in practice. These might have been prevalent during ancient times. [Su.Sa.Sharira Sthana.8/25-26][3], [Dalhana on Su.Sa.Sutra Sthana.13/3][3], [A.Hr.Sutra Sthana.26/53-55][2] In current times, the most common methods for bloodletting are puncturing, leech therapy and venesection. These three methods are described in details.

Puncturing (pracchana)

Pracchana is indicated in patients with good strength and if blood is accumulated locally or in clotted state.[Su.Sa.Sharira Sthana.8/25-26][3], [Dalhana on Su.Sa.Sutra Sthana.13/3][3], [A.Hr.Sutra Sthana.26/53-55][2]

Procedure

The body part is cleaned and a tourniquet is tied above the site. A sharp instrument like scalp blade is used to puncture skin over the affected site till appearance of small amount of blood. The puncturing is done from lower end in upper direction. Once punctured site should not be punctured again. Puncturing in oblique manner should not be done and it should be neither too deep nor too shallow. [Su.Sa.Sutra Sthana.14/26][3]The affected part is cleaned with decoctions and medicated ghee is applied and bandaged.

Venesection (siravyadha)

Siravyadha is indicated in the following conditions [Su.Sa.Sharira Sthana.8/25-26][3], [Dalhana on Su.Sa.Sutra Sthana.13/3][3], [A.Hr.Sutra Sthana.26/53-55][2]

  • If there is generalized vitiation of blood.
  • In patients with good physical and mental strength.
  • If the vitiated blood is spreading from one place to another.
  • If blood is vitiated by all the three dosha
  • In emergency conditions like poisoning [Su.Sa.Sharira Sthana.8/5][3]

Contraindication of siravyadha:

  • If the patient is weak, old person, children, pregnant lady, coward, debilitated due to diseases or due to excessive physical strain like excessive walking, sex etc.
  • Immediately after purificatory procedures like therapeutic emesis, purgation, enema etc. [Su.Sa.Sharira Sthana 8/3][3]
  • In too cold and hot climatic conditions.
  • In the diseases in which bloodletting is contraindicated [Su.Sa.Sharira Sthana 8/7][3] as mentioned above.

Procedure

The procedure of siravyadha is described in three steps:

  • Pre-therapeutic procedure (purvakarma)
  • Therapeutic procedure (pradhanakarma)
  • Post therapeutic procedure (pashchatkarma)

Pre-therapeutic procedure (purvakarma):

On the day of therapy, the person should undergo proper oleation and fomentation. Thick gruel is advised before the therapy.

Procedure of venesection with respect to site:

Venesection is done in a comfortable position either sitting or lying down. The torniquet is tied above the site of venesection. The site of puncture is cleaned, and superficial visible vein is punctured to let the blood out. The method of venesection in various sites like head, legs, arms, pelvis, back, shoulder, abdomen, chest, flanks, penis (erected), tongue, palate and root of teeth is described. [Su.Sa.Sharira Sthana 8/8][3]

Various specific sites for venesection in different diseases are described in following table:

Table 1: Disease specific sites of venesection
Disease Site of puncturing
Burning sensation in feet, tingling in feet, whitlow, erysipelas, gouty arthritis, plantar fasciitis, fissures of foot Vein situated 4cm (2 angula) above the vital point present in between big toe and its next toe (kshipramarma)
Inflammation of knee joint (Kroshtukashirsha), lameness, pain due to vata On calf region, 8cm (4 angula) above the ankle joint
Tumor in the neck (apachi) 4 cm (2 angula) below the vital point present in the center of calf muscle (indrabasti)
Sciatica (gridhrasi), Brachial neuralgia (vishwachi) 8cm (4 angula) either above or below the knee joint
Tumor in the neck (galaganda) Vein present at the base of the thigh
Disorders of spleen In the left arm either at the inner side of the elbow joint or in the area between little and ring finger
Ascites due to hepatic disorders (yakrutdalyodara), and kapha dominant ascites (kaphodara) In the right arm either at the inner side of the elbow joint or in the area between little and ring finger
Cough, dyspnea In the right arm either at the inner side of the elbow joint or in the area between little and ring finger
Dysentery (pravahika), pain in abdomen 4cm (2 angula)on the pelvis
Diseases of penis and semen (parivartika, upadamsha, shukadosha) Middle of penis
Hydrocele (mutravriddhi) Sides of the scrotum
Ascites (dakodara) In the abdomen below the umbilicus 8cm (4 angula) to the left of raphae
Internal abscess (antravidradhi), pain in flanks In between axilla and breast on the left flank
Wasting of arms (bahushosha), frozen shoulder (apabahuka) In between two shoulders
Intermittent fever that occurs on every third day In the middle of upper back (trika)
Intermittent fever that occurs on every fourth day Below the shoulder joint
Epilepsy (apasmara) Middle of the jaw
Insanity and psychosis (unmada) Temples, border of hair, chest, outer cantus of eye, forehead
Diseases related to tongue and teeth Above the ears
Diseases of nose, loss of smell Tip of nose
Diseases of eyes and head, blindness, ulceration of eye Inner or outer cantus of eye, forehead

[Su.Sa.Sharira Sthana 8/17][3]

Table 2: Size of puncture
Site Size Instrument
Muscular areas 2.4mm/size of barley (yava) Trocar (vrihimukha shastra)
Other areas 1.2mm/half the size of barley or size of a rice grain (vrihi) Trocar (vrihimukha shastra)
Over bony prominence 1.2mm/half the size of barley Small surgical axe (kutharika)

[Su.Sa.Sharira Sthana 8/9][3]

During the procedure, patient is observed for vital parameters like pulse and blood pressure.

Post-therapeutic procedure:

After letting out appropriate quantity of blood, maximum 650ml (1 prastha), the ligation should be removed.[Su.Sa.Sharira Sthana.8/16][3] The area should be cleaned and tight bandage should be applied at the site of puncture.

Leech therapy (jalaukavacharana)

Leech therapy is indicated in the following conditions

  • If vitiated blood is present in deeper areas below skin or in clotted stage.
  • In patients with poor mental and physical strength.
  • In the conditions of burning and pricking sensation.
  • Pitta dosha vitiation in blood (rakta)[Su.Sa.Sharira Sthana.8/25-26][3], [Dalhana on Su.Sa.Sutra Sthana.13/3][3], [A.Hr.Sutra Sthana.26/53-55][2]

Procedure

The procedure of leech therapy is described in following three steps:

Pre-therapeutic procedure (purvakarma):

Initially the leech is kept in a container of water mixed with turmeric powder. Then it is shifted to freshwater container.

In patients, local oil massage and sudation is done on the area of leech application. After that, the area is properly cleaned to remove oil and sweat over skin. It is rubbed with a cotton cloth.

Therapeutic procedure (pradhanakarma):

The leech is applied over the site. If leech is not biting, superficial incision is made over the site. The leech sucks blood and swells in size. The leech is then covered with a piece of thin and wet cotton.

Post -therapeutic procedure (pashchatkarma):

If the patient feels itching and pain at the site of bite, the leech is removed by sprinkling salt or turmeric powder over it. After removing the leech, salt or turmeric powder is applied over the mouth of the leech in order to expel the sucked blood. Light massage from its tail end to head can also be performed. When the blood is expelled by leech, it is placed inside a container with fresh water.

The site of leech application is washed with decoctions. Medicated ghee is applied and bandage with a cotton pad is done.

Assessment of therapy

Clinical features of optimal bloodletting

  • The blood flows out in a stream and it ceases by itself (without any treatment)
  • Feeling of lightness
  • Reduction in features of disease
  • Feeling of wellbeing [Su.Sa.Sutra Sthana.14/32-33][3]
  • If it is properly punctured, the blood flow may occur maximum for a period of 48 minutes (1 muhurta). [Su.Sa.Sharira Sthana 8/12][3]

Clinical features of inadequate flow during bloodletting

If the blood flow is inadequate, it will lead to the formation of swelling, burning sensation, redness, ulceration and pain. [Su.Sa.Sutra Sthana 24/29][3]

Clinical features of excess flow during bloodletting

Excess blood loss in bloodletting leads to headache, blindness, giddiness, depletion of tissues, seizures, burning sensation, hemiplegia, hiccups, dyspnea, cough, anemia and death. [Su.Sa.Sutra Sthana 24/30][3]

Complications

During leech therapy: Itching at the site of bite and non healing of bite wound are the common complications in leech therapy. Allergic reactions may also happen during leech therapy.

During venesection and puncturing: Fainting is the most common complication during these procedures. There may be secondary infections at the site of puncture.

Safety precautions

General precautions prior to procedure:

  • Examination of blood for contagious diseases like HIV
  • Blood examination for Hb%, TC, DC

General precautions during procedure:

  • Use personal protection measures like hand gloves by the physician
  • Avoid the procedure if the patient is hungry and during extreme climatic conditions.

General precautions after procedure:

  • Proper care of the wound with aseptic media.
  • Proper disposal of procedure wastes like blood, blood stained swabs, needle, scalpel etc.

Precautions for leech therapy:

  • Proper selection of leeches is very important.
  • Healthy, non poisonous leech must be used for therapy.
  • The leech should be preserved at ideal conditions. The container should be clean and water should be changed periodically.
  • Once used leech should never be used before the stipulated time.
  • Leech used for a patient with contagious disease should never be used again.

Precautions for venesection:

  • Eyes of the patient can be closed.
  • Try to perform the procedure in sitting or lying posture
  • If the procedure is to be performed in standing posture, manual assistance must be given to the patient.

Importance in preservation of health and prevention

In healthy person, bloodletting is indicated in autumn season.[Sha.Sa.Uttarakhanda.12/2][4] During this period, there is natural vitiation of pitta dosha and its abode rakta dhatu (blood tissue). Bloodletting therapy removes impurities due to vitiated pitta and rakta and thus prevents diseases. Bloodletting at regular intervals prevents occurrence and recurrence of diseases due to blood (rakta) such as skin disorders, tumors, edema etc.[Su.Sa.Sutra Sthana.14/34][3]

Importance in management of disease

Bloodletting is the principal treatment in diseases due to vitiation of blood. [Cha.Sa.Sutra Sthana 24/18] In treatment of visarpa, raktamoksha is the most effective treatment.[Cha.Sa.Chikitsa Sthana 21/141] Different modes of bloodletting are prescribed in the treatment of gouty arthritis (vatarakta) with other medical treatments. [Cha.Sa.Chikitsa Sthana 29/36] Venesection (siravyadha) is considered as half of the entire treatment in the field of Ayurvedic surgical procedures (shalya tantra).[Su.Sa.Sharira Sthana.8/23][3] The diseases that are not responding to oleation etc. treatment modalities,are immediately relieved through venesection.[Su.Sa.Sharira Sthana.8/22][3]

Mode of action

The removal of vitiated blood (rakta) in bloodletting therapy, results in removal of vitiated pitta and thus purifies the body. The blood loss due to the bloodletting results in the formation of fresh and pure blood. Thus, the amount of vitiated doshas gets reduced.

Contemporary views

Nowadays the methods of bloodletting as a treatment procedure includes the following

  • Therapeutic Phlebotomy: Puncturing the veins or arteries to treat certain ailments.
  • Cupping therapy (wet): Drawing the blood with the help of specialized cup like structures especially to reduce pain.
  • Medicinal leech therapy: Application of leeches to remove blood from particular sites.

Current researches

Removal of blood in a controlled manner is effective in treating many diseases. Bloodletting influences the body physiology at multiple levels. Bloodletting results in leucocytosis and decreases the activity of heart and other body functions for a short duration. After that, the blood is formed by hyperleucocytosis; acceleration of tissue changes takes place and the nervous system also gets stimulated.[5] Increased levels of ferritin and body iron affect insulin resistance and may result in metabolic syndrome. This can be prevented by reducing its levels in the blood through bloodletting and thus can improve health.[6]

A study on 15 patients of eczema, venesection (siravyadha) is found very effective in reducing burning sensation.[7] It is also observed effective in reducing the pain, stiffness and heaviness in sciatica[8] and lumbar spondylosis.[9] It may remove the obstruction (avarana) of pitta and kapha dosha leading to normal functions of vata dosha.[8]

Therapeutic phlebotomy

A study conducted on 64 hypertensive patients reported that the therapeutic phlebotomy results in reduction of body iron store, reduction in blood pressure and improvement in markers of cardiovascular risks and glycemic control. Phlebotomy leads to the reduction of viscosity of blood which results in the reduction of risk for thrombotic events like cardiovascular disease, cerebrovascular disease, arterial or venous thromboembolism etc. Since phlebotomy reduces the excess iron load in the body and reduces the blood viscosity, it is also proved to be effective in treating conditions like hemochromatosis, Porphyria cutanea tarda, Sickle cell disease and hyper-ferritinemia.[6]

Leech therapy

Medical leech therapy is widely used in the field of reconstructive and plastic surgery. Leech saliva contains more than twenty bioactive substances[10] including several analgesics and anti-inflammatory substances. Leech bite may have an antinociceptive action. Leech therapy may result in muscle relaxation as a result of decongestion due to blood and lymph loss and improvement of micro circulation. Placebo effect also may play a role in the overall effect of leech therapy.[11] Bdellins and Eglins present in leech saliva have anti-inflammatory actions. Broad spectrum anti-bacterial action against both Gram positive(S.aureus) and Gram-negative (Sal. Typhi and E. coli) bacterial strains is found in leech salivary secretions. Hirudin, calin and destabilase present in the leech saliva increase the micro circulation by reducing the viscosity of blood. Histamine and carboxypeptidase A inhibitor present in the leech saliva act as vasodilators and thus increase the blood flow at the site of bite. Leech saliva promotes the local immunity also.[12] In a study, it is reported that pain, stiffness, swelling and tenderness associated with osteoarthritis significantly reduced by the leech therapy.[13] In a study conducted on 14 patients, leech therapy is found effective in reducing the symptoms of eczema like itching, burning sensation, redness etc.[7] In a patient with nevus pigmentation, 5 session of leech therapy reported to reduce the pigmentation. Pitta is the responsible dosha for skin color. Leech therapy is the best treatment in case of vitiated pitta dosha.[14] Leech application is also reported to reduce the tenderness, pain and edema in thrombosed piles, in a study conducted on 12 patients. The antimicrobial and mucolytic properties of leech help to subside the pus and mucous discharge in thrombosed piles. Moreover, leech application has thrombolytic action.[15] Leech therapy in a patient having nasal furunculosis is reported to be effective in reducing the throbbing pain, erythema and inflammation.[12]

Cupping therapy

Through the cupping therapy, sub-atmospheric pressure suction is applied over a particular area which promotes peripheral blood circulation. It may also improve immunity. Altering the microenvironment through skin stimulation could transform into biological signals and may activate the neuroendocrine immune system. Some of the reported effects of cupping therapy are increasing pain threshold, improving local anaerobic metabolism, reducing inflammation, modulation of cellular immune system, promotion of skin’s blood flow and changing of biomechanical properties of skin. The physiological and mechanical signals produced as a result of mechanical stress on skin and local anaerobic metabolism during cupping therapy may activate or inhibit gene expression. During wet cupping, the superficial scarifications also may activate the wound healing mechanism and gene expression.[16]

List of theses done

  1. Mali Vimal R (2003): Role of Jalaukavacharana in the management of Raktapradoshaja vikaras w.s.r to arshas (thrombosed piles). Department of Shalyatantra, IPGT&RA Jamnagar
  2. Satasia Atul (2004): A clinical study on the management of vicharchika with Bhringrajarasayana and Jalaukavacharana. Department of Kayachikitsa, IPGT&RA Jamnagar
  3. Patel Pragnesh (2005): A comparative study of sira-vyadha and agni karma in the management of Gridhrasi w.s.r to sciatica. Department of Shalyatantra, IPGT&RA Jamnagar
  4. Bhimani Ketan (2005): Comparative study of Virechana karma and Jalaukavacharana in the management of Vicharchika. Department of Kayachikitsa, IPGT&RA Jamnagar
  5. Kapil A Pandya (2007): A comparative clinical study of Vamana Karma and Jalaukavacharana in the management of Vicharchika. Department of Panchakarma, IPGT&RA Jamnagar
  6. Hiren Raval (2010): A Comparative Clinical Study of Raktamokshana by Jalaukavacharana and Shiravedhana in the Management of Vicharchika (Eczema). Department of Panchakarma, IPGT&RA Jamnagar
  7. Vaneet Kumar (2013): A comparative clinical study of Agnikarma and Siravedha in the management of gridhrasi w.s.r to sciatica. Department of Shalyatantra, IPGT&RA Jamnagar
  8. Paikrao Sumedh Narayanrao (2014): A clinical study on siravedha and vaitaranabasti in the management of gridhrasi with special reference to sciatica. Department of Panchakarma, IPGT&RA Jamnagar
  9. Joshi Foram P (2016): A comparative clinical evaluation of Agnikarma and Raktamokshana in the management of sandigatavata w.s.r to lumbar spondylosis. Department of Shalyatantra, IPGT&RA Jamnagar
  10. Nandini Durgesh (2017): A comparative clinical evaluation of Agnikarma and Raktamokshana in management of gridhrasi (sciatica). Department of Shalyatantra, IPGT&RA Jamnagar
  11. Madhuri G Rai (2018): A clinical efficacy of Raktamokshana and Trayodashangaguggulu in the management of katigatavata w.s.r to Lumbar spondylosis – A randomized controlled clinical trial. Department of Shalyatantra, IPGT&RA Jamnagar

More information

Vidhishonitiya Adhyaya

Abbreviations

Cha. = Charak, Su. = Sushruta, A. = Ashtanga, S. = Sangraha, Hr. = Hridayam, Sa. = Samhita, Sha. = Sharangadara

List of References

The list of references for Raktamoksha in Charak Samhita can be seen here

References

  1. VC Patil. Principles and practice of pancakarma. New Delhi:Chaukhabha publications;2016.Chapter 15, Raktamokshana Karma (Bloodletting therapy);p.571.
  2. 2.0 2.1 2.2 2.3 2.4 2.5 Vagbhata. Ashtanga Hridayam. Edited by Harishastri Paradkar Vaidya. 1st ed. Varanasi: Krishnadas Academy;2000.
  3. 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 3.15 3.16 3.17 3.18 3.19 3.20 3.21 3.22 3.23 3.24 3.25 3.26 Sushruta. Sushruta Samhita. Edited by Jadavaji Trikamji Aacharya. 8th ed. Varanasi: Chaukhambha Orientalia;2005.
  4. Sharangadhara, Sharangadhara Samhita. Edited by Parasuram Shasthri. 3rd ed. Varanasi: Choukhamba Orientalia;1983.
  5. Sarvesh KS, Kshipra R. Pachakarma parigyan A text book on panchakarma (principles and practices). Varanasi:Chaukhambha prakashak;2019.Chapter 10, Raktamokshana Karma;p.656.
  6. 6.0 6.1 Singh SK, Rajoria K, Medical leech therapy in Ayurveda and biomedicine e A review, J Ayurveda Integr Med, https://doi.org/10.1016/j.jaim.2018.09.003
  7. 7.0 7.1 Raval HN, Thakar AB. Role of Raktamokshana by Jalaukavacharana and Siravedhana in the management of Vicharchika (Eczema). Ayu. 2012 Jan;33(1):68-72. doi: 10.4103/0974-8520.100314. PMID: 23049187; PMCID: PMC3456867.
  8. 8.0 8.1 J Vineet Kumar, Tukram SD et al. A comparative clinical study of Siravedha and Agnikarma in management of Gridhrasi (sciatica). Ayu. 2014 Jul-Sep;35(3):270-6. doi: 10.4103/0974-8520.153743.
  9. F Joshi, V Mahanta et al. Effect of Agnikarma (therapeutic heat burns) and Raktamokshana (therapeutic bloodletting) in the management of Kati Sandhigata Vata (lumbar spondylosis). Ayu. 2019 Apr-Jun;40(2):79-88. doi: 10.4103/ayu.AYU_142_16. Epub 2020 Mar 20.
  10. Detlev K, Michael A et al. Medicinal leech therapy in venous congestion and various ulcer forms: Perspectives of Western, Persian and Indian medicine. J Tradit Complement Med. 2019 Aug 3;10(2):104-109. doi: 10.1016/j.jtcme.2019.08.003. eCollection 2020 Mar.
  11. Hohmann CD, Stange R, Steckhan N et al. The Effectiveness of Leech Therapy in Chronic Low Back Pain. Dtsch Arztebl Int. 2018 Nov 23;115(47):785-792. doi: 10.3238/arztebl.2018.0785.
  12. 12.0 12.1 Amol SK, Dhirajsingh SR, Sourabh GD. Management of Recurrent Nasal Vestibular Furunculosis by Jalaukāvacaraṇa and Palliative Treatment. Anc Sci Life. 2017 Apr-Jun;36(4):220-224. doi: 10.4103/asl.ASL_190_15.
  13. PK Rai, AK Singh et al. Efficacy of leech therapy in the management of osteoarthritis (Sandhivata). Ayu. 2011 Apr;32(2):213-7. doi: 10.4103/0974-8520.92589.
  14. Rastogi S, Chaudhari P. Pigment reduction in nevus of Ota following leech therapy. J Ayurveda Integr Med 2014;5:125-8.
  15. Bhagat PJ, Raut SY, Lakhapati AM. Clinical efficacy of Jalaukawacharana (leech application) in Thrombosed piles. Ayu. 2012 Apr;33(2):261-3. doi: 10.4103/0974-8520.105248. PMID: 23559800; PMCID: PMC3611649.
  16. Aboushanab TS, AlSanad S. Cupping Therapy: An Overview from a Modern Medicine Perspective. J Acupunct Meridian Stud. 2018 Jun;11(3):83-87. doi: 10.1016/j.jams.2018.02.001. Epub 2018 Feb 7. PMID: 29436369.