Raktamokshana (रक्तमोक्षणम्)

Raktamokshana is one of the 5 Panchakarmas practiced in Ayurveda. Raktamokshana literally means blood letting procedure. The vitiated rakta inside body which is causing various different illnesses and not responding to the general line of treatment with internal medicines is removed out of the body through this procedure. It is one of the shodhana (cleansing or detox) type of chikitsa described in Ayurveda. Indications, contraindications, types, eligibility criteria, procedure, effects and other relevant details on Raktamokshana have been described in Ayurveda literature in depth.

Introduction

Acharya Sushruta has given equal importance to Rakta dhatu like doshas. So much so that he believes that Rakta dhatu should be considered as the 4th Dosha in body. While praising the role of rakta in sustaining the life he says that,

देहस्य रुधिरं मूलं रुधिरेणैव धार्यते | तस्माद्यत्नेन संरक्ष्यं रक्तं जीव इति स्थितिः ||४४|| (Su Su 14.44)

Meaning: Rakta is the root of deha (shariram / Physical body) and that is the only one which holds (sustians) this deha. Thus one should carefully guard Rakta since that is the life.

Owing to this crucial role of rakta in maintaining the human body it becomes necessary to keep the rakta dhatu in healthy state. If it gets afflicted by any dosha it can certainly dispaly various signs and symptoms of diseases. In some instances when the impurities in rakta are so hugi when those cant be treated with medicines are need to taken out there has to be a way through which this can be facilitated. Raktamokshana thus provides the method and therapy to cleanse the Rakta dhatu.

Raktamokshana is the unique para-surgical therapy which has references only in Ayurveda literature which dates back to 2000BC. Raktamokshana is a modality of treatment where in “rakta” meaning blood which is vitiated is let out of the body using surgical instruments (and non-surgical instruments) in certain quantities and in a controlled manner under the observation of a certified Vaidya or physician. Commonly called as blood detox therapy it has widespread advantages in various skin diseases as well as systemic disorders wherever the vitiated rakta dhatu is involved. Rakta dhatu can get vitiated with any of the 3 doshas namely vata, pitta and kapha. The tools or instruments and the procedure of Raktamokshana varies as per the vitiating dosha. This is the basis for various types of raktamokshana procedures practiced in Ayurveda.

Etymology

In Vachasapatyam, the term Raktamokshanam has been explained in Samskrit as below,

रक्तमोक्षणं, क्ली, (रक्तस्य मोक्षणम् ।) शोणित- स्रावः । (Vachas)

Meaning: The procedure in which Shonit (samskrit term for blood, synonym for rakta) srava (means secretion or flow) happens is known as Raktamokshana.

Classification

The panchakarma therapy Raktamokshana is classified into various types based on the use of tools and the targeted dosha vitiating Rakta. These types and sub-types are listed below,

Classification of Raktamokshana procedure

Using Shastra (Using some surgical instrument)	Without Shastra (Using non-surgical tools)
Siravyadha (venesection)	Jalauka avacharana (leech therapy)
Pracchana (scraping)	Shringa avacharana (using horn)
	Alabu avacharana (using alabu fruit)
	Ghati yantra avacharana  (using pot)

siravyadha – literally means venesection, a type of ayurvedic procedure where certain vein is punctured, so the blood can flow for certain period for eradication of vitiated rakta and pitta dosha. This is a controlled procedure and occurs under the observation of a Vaidya or physician.

Indications

Rakmokshana is done primarily to remove the vitiated rakta dhatu out of the body. Such necessity arises when there are certain medical conditions like below wherein thus Raktamokshana is indicated.

1. Apachi (enlargement of glands)
2. Arbuda (tumor like growths)
3. Arsha (piles/haemorrhoids)
4. Daha (burning sensation)
5. Sopha (swelling)
6. Dushta artava (menstrual disorders)
7. Kushta (skin disorders)
8. Raktapitta (bleeding disorders)
9. Tandra (malaise)
10. Vatarakta (arthritis)
11. Gaurava (heaviness)
12. Pleeha roga (spleen related diseases)
13. Yakrit roga (liver disorders)
14. Raktaja vikara (blood vitiation and disorders) Etc

Acharya Sushruta has also praised the efficacy of Raktamokshana by quoting that if Raktamokshana is done as a preventive therapy in those who are prone to Twak-doshas (skin related diseases), or tendencies to develop Granthi (tumors), Shopha (swellings) and Rakta dhatu related disorders, they can prevent the occurrence of these.

त्वग्दोषा ग्रन्थयः शोफा रोगाः शोणितजाश्च ये | रक्तमोक्षणशीलानां न भवन्ति कदाचन ||३४|| (Sush. Samh. 14.34)

Contraindications

In Raktamokshana vitiated blood is removed out of the body. Rakta in nonvitiated state protects and holds the body and thus called the root of body and life. Therefore its removal should be done with utmost care. If done inappropriately or when contraindicated it has potential to develop fatal complications hence contraindications to this procedures should be properly known. There are certain physiological and pathological conditions wherein the procedure of Raktamokshana is not recommended. The states where Raktamokshana is contraindicated are listed below,

1. Baala (children)
2. Bhiru(who is afraid)
3. Daurbalya (weak)
4. Garbhini(pregnant)
5. Pandu (anaemia)
6. Pakshaghata (paralysis)
7. Vriddha (elderly)
8. Person in whom it is indicated but the pre-procedures like Snehanam (oleation therapy) and swedanam (sudation) are not done or overdone.
9. Shwasa and kasa ( medical conditions presented as dyspnoea or coughing)
10. Srvanga shotha (generalised swelling all over the body)
11. Related to the weather or time to perform Raktamokshanam- In extremely cold or hot weather, excessively windy or cloudy weather

Siravyadha (venesection method of Raktamokshana)

Siravyadha is a type of raktamokshana wherein the vitiated blood is let out of the body by puncturing a vein (also known as venesection method). The blood flows for certain period till eradication of vitiated rakta and vitiating doshas contained in it. This is a controlled procedure and performed under the observation of a skilled Vaidya or physician. This method of raktamokshana is usually indicated in conditions like kushtha (skin diseases) , shopha (certain types of swellings), arbuda (tumours), visarpa (erysipelas), granthi (nodules) etc. However there are some contraindications for this procedure as well. Since through this procedure significant amount of blood can flow out of the body it is not suitable in children, old age, pregnant ladies. Also in conditions like klaibya (impotency), pakshaghata (paralysis like nurological disorders), extreme wekness, debilitating diseases, giddiness, tiredness sivavyadha is contraindicated.

How Siravyadha is performed?

Siravyadha is done under the exper supervision of a learned vaidya. The patient is first thoroughly examined by ashtavidha pariksha and dashavidha pariksha. Apart from these blood pressure, temperature etc are also examined. If required certain biochemical test are also conducted.

Atura siddhata (preparation of patient)

The preparation starts 3-5 days before the actual procedure. It includes snehapana, which means patient or individual is administered ghee or oil (depending on his medical condition) orally in increasing pattern until the Vaidya decides for a period of 2 to 3 days. 

Diet- There are some specific diet plans whic need to be followed while taking the ghee or oil and even just a day before the actual procedure. And on the day of siravyadha just before the karma yavagu (rice gruel) is given to patient to avoid giddiness.

Pradhana karma of siravyadha

Abhyanga and swedana- On the day of siravyadhana karma, abhyanga is done with oil and swedana or sudation is performed. This is either whole body or affected part only, which is decided by the Vaidya.

The patient is given a specific position depending upon the vein location selected to puncture. A vaidya selects the vein to be punctured. The vein is raised by tapping on it with fingers. A needle is carefully inserted, and the vitiated blood is let flow. The quantity of the blood to let flow is decided by the Vaidya based on certain parameters mentioned in treatises. (sush.shar.8.16) Based on the quantity, quality, colour etc of blood and symptoms, level of shuddhi or purification is decided by Vaidya. In this entire procedure the patient is continuously monitored to forsee the complications if any arise and also to decide the level of purification achieved through the process. Once the desired amount of blood is removed out the procedure is stopped by Vaidya. A tight dressing is applied if needed to stop the bleeding. Gentle massage is done around the punctured area.

Light food, which is easily digestible, mildly unctuous, devoid of sourness needs to be taken. Yusha, yavagu, peya are administered mostly. Patient is advised to avoid exercise, cold, windy exposure, day sleep, pungent alkaline substances in food, excess talking, grief etc for one month.

Prachhana Karma (Scraping method of Raktamokshana)

The term prachhana means scraping or lacerating. Thus a type of raktamokshana wherein the vitiated blood is let out of the body by performing scraping or creating lacerations over the affected part is known as prachhana karma. After making the necessary preparations and assessing the patient thoroughly prachhana is planned. The affected area is cleaned well. Bandhana (ligation) is done above the site of pracchana. A sharp instrument like needle or similar surgical tool is taken and scraping or scarring is done over the surface of skin to avoid injuries to muscle, tendons bones, veins. Only the superficial capillaries get scarred and bleeding occurs. Pracchana is done in a certain manner, straight, not too superficial not too deep not in any oblique way. The blood can let flow for certain period until the Vaidya decides which is based on certain parameters. This whole procedure occurs under the thorough observation of Vaidya in controlled environment. The wound is lastly cleaned and bandaged using medicated oil or ghee.

Jalauka avacharana (Leech therapy for Raktamokshana)

Jalauka is the samskrit term which refers to the leech. It is a slimy blood sucking ectoparasite that live in water. Jalauka or leeches are of many different types. Some are also toxic in nature while some of them are medicinal. Only certain types of jaluaka having therapeutic or medicinal benefit are selected to be used for raktamokshanam or blood letting therapy in Ayurveda. Thus blood letting with the help of leeches is known as leech therapy or hirudotherapy. This is a unique procedure mentioned only in Sushrut Samhita. Jalauka removes the vitiated blood from the body. The whole procedure takes pace in a controlled manner under the observation of a Vaidya. Jalauka avacharana has high efficacy in treatment of blood related disorders and thus is one of the supreme treatment aspects in management of it. It is generally selected method for raktamokshana when the vitiated blood affects small limited part of the body which means it is used as a local treatment. It is generally not indicated in systemic disorders spread all across the body caused by vitiated rakta dhatu.

Procedure

In this method along with the patient, the jalaukas are also need to be prepared. Types of jalaukas and maintenance of jaluakas has been described in depth in Sushruta samhita.

• The area or selected site for raktamokshana of affected body part is prepared by abhyanga (applications of oil), swednam (sudation /fomentation) for ease of dosha nirharana (expulsion of morbid doshas) in the form of rakta mokshana. After swedana “neem” churna (powder of Azardiracta indica) is rubbed gently. The procedure and preparation may differ as per the practice and experience of a vaidya.
• This takes place to remove any dead superficial skin. Also helps easy attachment of jalauka or leech.
• In this method of raktamokshanam, the prepared jalauka(leech) is held with a small clean cloth or cotton etc and placed on the desired site. The jalauka when applied attaches itself to the skin surface and starts intaking blood. Attempts are made to make jalauka get attached to the site. Once it attaches, drops of cold water is poured continuously to keep it wet and active since it lives in the water. Later after the leech starts sucking blood Vaidya observes the whole process. There are few parameters which decides whether the jalauka(leech) is attached appropriately, when to stop, how to stop therapy and many other. These are decided by the Vaidya itself. For example, when the leech gets attached, it attains a horse-shoe shape. The sucking action is like the breathing pattern of a human.
• There are certain signs and symptoms based on which a Vaidya decides whether to stop the therapy or not and whether necessary quantity of vitiated blood has been removed from the body appropriately. After the therapy, jalauka (leech) is removed by sprinkling some herb/salt/turmeric over the mouth of leech.
• After detaching the leech, the site is wiped with clean cotton, and might be washed with herbal decoction. Later medicated ghee is applied at the site and compression is done.
• Leech is also taken care of after the procedure. Jalauka (leech) is made to vomit the vitiated blood that it had sucked during the procedure. This is also done skillfully, so as the leech should not be harmed. the leech is made to vomit the entire quantity of sucked blood, this is important step done by Vaidya to avoid disease that might affect leech.

Shringa Avacharana (Suction therapy using cow's horn for Raktamokshana)

“Shringa” means horn and “avacharana” means application. Thus, Shringavacharana literally translates to application of horn. Precisely, shringa avacharana means blood letting with the help of cow’s horn. But now a days, an empty syringe is used in the place of cow's horn of which the anterior 1/5th part is removed to facilitate suciton.

Procedure

• Once the patient screening and examination is thoroughly done the procedure is planned. Usually done to treat a localized affliction and not for generalized health conditions. Initially the area where blood letting is to be done is cleaned and dried thoroughly. Pracchana karma (see above sections for details) or scraping with needle is done at the site where shringa avacharana is to be done.
• A syringe prepared to perform raktmaokshan is kept on the site and the piston is pulled to slowly to create a negative pressure. This mechanism draws blood inside the syringe. Very little amoun tof blood is removed through this type of a procedure and thus in patients who are sukumara (delicate) this kind of bloodletting is performed.
• The syringe is removed, and the wound is bandaged with medicated ghee.
• The shringa or horn itself contains vata pacifying properties, thus when this method is done classically there are far higher results, but with syringe the results achieved are quite clos ethe original method.
• This whole procedure requires skill of a Vaidya and occurs under the strict observation of a Vaidya.

Alabu avacharana (Traditional Cupping therapy for Raktamokshana)

Alabu refers to a fruit cum vegetable which is white in color and soft in texture, more commonly known as bottle gourd (Lagenaria vulgaris). This is a type of bloodletting where dried alabu (bottle gourd) is used and vacuum is created using ignited candle to draw vitiated blood thus is a unique but at the same time less commonly practiced bloodletting procedure.

Procedure

All the materials and equipment’s which are required for the procedure are kept ready beforehand.

Alabu phala (bottle gourd) preparation: It needs to be dried and the contents emptied to make it eligible to be used for procedure. Later a circular small hole is made at one end.

The site for alabu application is scraped with needle, minute laceration is created performing pracchana karma.

Leaf of alabu phala is placed over the skin surface slightly over lacerated skin. A candle is placed on it and ignited. Later open end of alabu phala is placed over the candle.

Here a vacuum is created and due to negative pressure because of candle, blood oozes out of the site of pracchana karma.

This is done for around 10 – 15 mins. Then the alabu phala(bottle guard) is removed at once.

Later the wound is cleaned and bandaged with herbal ghee.

This is not a very common procedure and done in a controlled environment under the observation of a skilled Vaidya.

Ghati Yantra Avacharana (Suction therapy using pot for Raktamokshana)

This is a type of bloodletting procedure using “ghati” meaning pot. Here a vacuum is created using ignited candle and using negative pressure blood is drawn. This method is same as alabu therapy. Only ghati or pot is used instead of alabu.

Practical considerations

• Raktamokshana is done in consideration with rogi bala (strength of patient) and strength of disease.
• The type of raktamokshana procedure suitable for a particular patient or diseased condition is selected basedon multiple factors like vitiating dosha, affected part of body, strength of the patient etc.
• Raktamokshana is the choice of treatment when the vitiated rakta dhatu doesnt respond to the regular line of shamana chikitsa or the condition keeps on relapsing indicting that rakta is aggravated to a level which can not be balanced unless the vitiated rakt adhatu is removed out of the body.
• Raktamokshana is done in various sittings, which means therapy is done until the Vaidya decides whether doshas have been expelled out appropriately or not.

Mode of action

Although blood letting is also known to modern medical system, the application of it in it and in Ayurveda is quite different. Various methods employed in raktamokshana in Ayurveda are not in practice in modern medical science e.g. jalaukavacharana. There are certain researches which have tried to find out the plausible mechanism of action in various types of Raktamokshana procedure.

Many studies have found that leeches have various bioactive molecules in their secretions (e.g., Hirudin). These molecules have analgesic, anti-inflammatory, platelet inhibitory, anticoagulant functions and many others. Leech is a distinct example of an invertebrate, which possesses a highly developed mechanism by which they prevent blood clotting. There are many studies stating the anticancer effects of leech saliva extracts. Since coagulation is related to metastasis and tumour progression, blocking the cascade can have an antitumour effect.

Systemic bloodletting is restricted to few conditions for e.g., Polycythaemia, hemochromatosis in modern medical science, but Raktamokshana has shown its miraculous effects in many diseases. The major difference behind the applicability of this procedure in 2 streams is that, modern medicine looks at it as a quantitative removal of blood while Ayurveda considers this procedure as a purification by eliminating rakta dhatu vitiated by doshas and not as blood. The difference between blood and rakta dhatu makes the huge difference between perspectives of Ayurveda and modern medical system to look at the blood letting procedure. Bloodletting in any form requires removal of blood at a superficial level, might be from capillaries or superficial distribution of veins. Raktamokshana removes the old, damaged blood cells and helps formation of new, this reduces the workload on liver and spleen. Removal of small quantities of blood, reduces volume of blood from body which directly impacts the pressure of blood over the blood vessels and heart. In conditions of necrosis, or graft implantations, leeches or raktamokshana is used to establish adequate blood supply locally.