The Ultimate Beginner’s Guide to Raktamokshana – Blood Letting in Ayurveda

Raktamokshana is the procedure in Ayurveda to purify the blood. The word Raktamokshana has two words – Rakta is blood and mokshana is to leave, so, to let the blood out is raktamokshana. Sushrutha mentions this procedure as one among five purificatory procedures. The therapy is done to expel the vitiated blood and reduce the toxic substances preventing various rakta pradosha vikara (blood-borne diseases). It can be divided into three types, namely, Shastravidhi, Anushastra vidhi, and Ashastra vidhi. Rakta is considered as the fourth dosha by Sushrutha and hence Raktamokshana is the ideal treatment for rakta pradoshaja vikara.  

Types of Raktamokshana

Raktamokshana can be classified into three types depending on the type of instruments used:

1. Shastra
2. Anushastra
3. Ashastra

Shastra: The bloodletting therapy done is with the help of sharp instruments. The   methods employed are:

1. Prachchanna – This is the scarification.
2. Siravyadhana – Venepuncture.

Anushastra: Raktamokshana is done without using sharp instruments, but blunt instruments are used and are done to those who are intolerant or sensitive. These are:

1. Shringa Avacharana (horn application)
2. Alabu Avacharana (bottle gourd application)
3. Ghati yantra Avacharana (cupping therapy)

Ashastra: Raktamokshana is done using no sharp instruments and is indicated for highly intolerant or sensitive patients.

• Jalauka avacharana (leech therapy)

Ideal period for Raktamokshana

• Sharad Rutu (autumn season) is the ideal period for Raktamokshana.
• The therapy can also be done after Swedana karma (sudation) and Yavagu pana (intake of barley gruel).
• Avoid bloodletting therapy during Ushna kala (hot climate), Pravata (when there is heavy wind or breeze), and Abhra kala (cloudy days).

Indications of Raktamokshana based on dosha

• Vata dushita Rakta – Shringa
• Pitta dushita Rakta – Jalauka
• Kapha dushita Rakta – Alabu
• Vata-Pitta dushita Rakta – Shringa
• Vata-Kapha dushita Rakta – Alabu or Ghati yantra

Indications of Raktamokshana based on the location of Rakta dushti

• Twachasthitha (superficial) – Shringa, Alabu
• Avagaadha (deeper tissues) – Jalauka
• Ekadoshita and Pinditarakta – Prachanna
• Sarvangavyapi Rakta dushti – Siravyadhana

Indications of Raktamokshana based on the type of patients

• Sukumara (sensitive / intolerant) – Alabu and Shringa
• Parama Sukumara (highly sensitive or intolerant) – Jalauka
• Asukumara (tolerant) – Prachanna and Siravyadhana

Raktamokshana based on Specific disease indications

• Kushta (skin diseases)
• Karna palli roga (diseases of the ear lobe)
• Shlipada (filariasis)
• Vishadushita Rakta (case of poisoning)
• Visarpa (erysipelas)
• Granthi (cystic lesions)
• Stanya roga (diseases of breast)
• Krimidanta (dental caries)
• Dantapupputa (cystic lesions of gums)
• Galashaluka (inflammatory conditions of throat)
• Oshta roga (lip disorders)
• Arbuda (tissue enlargements)
• Upadamsha (sexually transmitted infections)
• Vidradhi (abscess – all types of vidradhi excluding the one caused due to combined effects of tridosha)

Raktamokshana should be avoided in

• Garbhini (pregnancy)
• Pandu (anemia)
• Udara roga (diseases of the abdomen)
• Sarvanga shotha (generalized edema)
• Emaciated
• Shosha roga (tuberculosis)
• Mada (delirium)
• Murcha (unconscious)
• Obstruction to the passage of flatus, urine, and stools.

Procedure of Raktamokshana

The procedure is divided into three phases: Purvakarma, Pradhana karma, and Paschat karma.

Purva karma: The prior preparations of the main procedure

• The patient should be screened based on the indications and contra-indications for Raktamokshana.
• Snehana (oleation therapy)and Swedana (sudation therapy) are administered to the patient.
• A light diet like a gruel or liquid diet is advised to the patient.
• The patient is either asked to sit or stand or even lie in the supine position.
• The part where the main procedure is to be done is selected, exposed, and made sterile.
• The part above the site of the procedure is tied with the help of a tourniquet or cloth.
• Tying should neither be too tight nor too loose.

  Pradhana karma: The main procedure depends on which type of Raktamokshana is done.

1. Pracchanna karma – In this procedure, at the selected part, small-sized multiple wounds are made using sharp instruments. The wounds made should be straight, fine, proportionate, and not very close to each other. Vital points where there are nerves, blood vessels, joints, tendons, ligaments, etc. are to be avoided. The amount of blood that can be drained in Pracchanna karma is one angula as per Ayurveda reference. After the procedure, the wound site must be cleaned with antiseptic measures and dressing is done.

• Siravyadhana – Select the area where the veins are visible and then the vein must be made prominent by tapping on the vein or by flicking the finger against the vein. The vein becomes palpable. Select the mid-part of the vein and using a scalpel or needle a small incision is made or the vein is punctured. The size of the incision as explained in the classical references of Ayurveda is, in muscular areas, the size of Yava Pramana (barley grain), in the parts near the bony structures or any other area, the size is half of the barley grain. Allow the blood to flow in a stream till it stops bleeding on its own within one muhurtha (45 minutes). The amount of blood that can be drained is one prastha. After the procedure, the wound site must be cleaned with antiseptic measures and dressing is done.

• Shringa – The bloodletting is done using a cow’s horn. The area is selected and exposed. Small, shallow pricks are made and then the horn is placed on these pricks. Air is sucked from the other opening such that a vacuum is created. With this, vitiated blood is allowed to ooze or flow. The amount of blood to be drained is 10 angula Pramana. After the procedure, the wound site must be cleaned with antiseptic measures and dressing is done.

• Alabu – The bloodletting is done using dried vegetable gourd or dried long fruit of the Cucurbitaceae family. The area is selected and exposed. Small, shallow pricks are made and then the gourd or fruit is placed on these pricks. Air is sucked from the other opening such that a vacuum is created. With this, vitiated blood is allowed to ooze or flow. The amount of blood that can be drained is 12 angula Pramana. After the procedure, the wound site must be cleaned with antiseptic measures and dressing is done.

• Jalauka – The bloodletting therapy is done using leech. For the leech therapy, select the medicinal leeches. These are to be preserved in a container filled with turmeric water. The area is selected and exposed. Small, shallow pricks are made. Leeches are held with cotton gauze pieces and applied to these pricks. They start biting and get attached to the skin. In case, they do not get attached, apply some butter or ghee to its mouth. Once they get attached, leeches start sucking the blood. The sucking is confirmed if there is a raising of the neck of the leech-like a horseshoe-shaped and visible peristaltic movements. At this point, cover the leech with a wet cotton pad or gauze. Allow the leech to suck the blood until the patient starts experiencing the pricking pain or itching at the site. Detach the leeches from the site. If the leech does not get detached, sprinkle some salt or turmeric on its mouth. Once detached, the leeches are squeezed from the tail end downwards to the mouth and let the leech vomit the sucked blood and kept back into the turmeric-filled containers. The amount of blood that can be drained in leech therapy is one Hasta Pramana. After the procedure, the wound site must be cleaned with antiseptic measures and dressing is done.

• Ghati yantra – It is called fire cupping therapy. Small, shallow pricks are made over the selected part. An earthen pot or nowadays glass cup is used. The glass cup is smeared with flammable liquid and set on fire. Before the fire extinguishers, it is placed on the pricks. The negative pressure created in the cup draws the blood in the cup.

Paschat karma

• After the procedure is completed, a gentle massage over the affected area with medicated oil or ghee is done.
• If the bleeding does not stop, apply gentle pressure with a cotton piece or tie a bandage / sprinkle some cold water or give cold compressions/ cauterization/and apply some corrosive agents. 
• Give a diet that is easily digestible, improves the blood, and provides strength.
• Instructions to avoid excess talking, laughing, heavy exercise, and exposure to too much hot or cold weather.

Symptoms of adequate and inadequate Raktamokshana

Symptoms of adequate bloodletting therapy are relief from the symptoms and a feeling of lightness in the body.

Symptoms of inadequate bloodletting therapy are headache, blurring of vision, burning sensation, hiccough, dyspnea, and cough, and may even lead to death.

Conclusion

Rakta is considered as the fourth dosha in some references of Ayurveda, Raktamokshana is a one among Panchakarma as per Sushrutha. It removes the vitiated blood from the body. The dosha, type of patient, period of administration and the diseases are to be screened and therapy is administered. This is a para-surgical procedure and is divided into three types, Shastra, Anushastra, and Ashstra. The measures of Purva karma, pradhana karma, and paschat karma are to be followed properly to avoid further complications. Diet and lifestyle regimen according to the procedure is important and helps regain strength.

References

1. AN IN-DEPTH REVIEW OF RAKTAMOKSHANA (BLOODLETTING) THERAPY, International Ayurvedic Medical Journal, February 2022, p.374-380.
2. RAKTAMOKSHANA – ANCIENT BLOODLETTING TECHNIQUE: A REVIEW, International Journal of Ayurveda and Pharma Research, October 2022, Volume 10, Issue 10, p.106-110.
3. 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.
4. Andhare, R., Dandekar, P., Shrivas, Y., Bankar, N. and Patil, S. (2021) “Physiological Aspect of Raktamokshana – A Critical Review”, Journal of Pharmaceutical Research International, 33(63A), pp. 107–112. doi: 10.9734/jpri/2021/v33i63A35221.