prachhna and siravyadha in ayurveda raktamokshana treatment

It includes explanation of siravyadha and prachana raktamokshana

1. Pracchana and siravyadha .

2. RAKTAMOKSHANA KARMA (BLOODLETTING THERAPY) Raktamokshan is one among the panchashodhana i.e.vamana,virechana,basti,shirovirechana and raktamokshan . Def.:- रक्तस्य मोक्षणं रक्त मोक्षणम् । ( Sha.Ka.Dru ) Letting out impure blood from the body is known as Raktamokshana Raktamokshana is a procedure of removing the vitiated rakta in diseases caused mainly by Rakta and Pitta. It is carried out either by using sharp surgical instruments or by parasurgical measures

3. Raktamokshan classification Raktamokshan I. शस्त्रकृतः II. अनुशस्त्रः 1. सिराव्यधन 2. प्रच्छान 1. शृङ्ग 2. अलाबु 3. जलौका 4. घटीयन्त्र

4. प्रच्छानकर्म Def.:- The procedure of incising the skin superficially and there byaccomplishing the bloodletting is known as Prachchhana . This procedure is specially indicated to eliminate Pindita Doshas . Or It is type of Raktamokshana wherein the affected area is scarified or scraped with a sharp instrument. Indications:- Pindit rakta - hematoma;Fluid accumulated under skin, subcutaneous tissue ; Cellulitis; in early stage of filariasis;in case of snake or scorpion bite As a Pürvakarma before Śringa , Alabu or Ghați application.

5. Contraindications Bleeding disorders, vein puncture, on marmasthana

6. Procedure:- The affected area should be cleaned well. Then ligation ( Bandhana ) should be made above the site of Pracchana Scalp blade with sharp edges taken and then scrap the area avoiding the Snayu , Sandhi, Asthi , Marma , Sira . The Pracchana should be as follows- Rju -straight Nati Uttana - not too superficial Näti Gambhira - not too deep Asankirna - not very near to other Pracchana line
Na Turyak -not obliquely. After pracchana karma dressing is done with Antiseptic solution and aseptic precautions.

7. Complications and management -Excessive bleeding : excessive bleeding may occur sometimes due to more pressure,chance of cutting the vein.This is managed with stambhana with Kashaya and Sheeta drugs. If not stops then pachana should done with Shankha Bhasma pratisarana . - Marmaviddha : If Marma injury occurs, then Marma Gulika Lepa for external application, Marma Kashayam 20ml twice, and internally- Gandha Taila 10 drops with milk.

8. Siravyadha ( venesection) There are total 10 महासीरा’s which transports रस and ओज to whole body,like a water carrying channels irrigates the whole garden. This 10 महासीरा’s further divided into several multiple capillaries. Total no. Of siras are 700 in no. They are of 4 types: वातवह (175), पित्तवह (175) , काफवह (175) & रक्तवह (175) among them 602 we can’t cut . Def.:- Siravyadha is one of the important methods of Rakthamokshana . The surgical procedure of puncturing a vein for therapeutic purpose, after preparation of patient is called as siravydhana . Raktamokshana , by the method of Siravyadha is preferred in physically strong as well as courageous people.

9. Importance of siravyadh सिरव्यध चिकित्सार्ध संपूर्ण वा चिकित्सितं । शल्यतन्त्रे स्मृतो यद्वद्वस्तिः कायचिकित्सते ।। (Su.Sha.8/23) Siravyadha is considered to be as half the treatment or even a complete treatment in Shalya tantra , just as Basti is considered in Kayachikitsa . By siravyadh alone,all diseases will be cured from their roots,just like rice and other crops in the field dry out completely by removing the bunds of field. The disorders which are not cured by Sneha , Lepa etc are cured inspontaneously by Siravyadha .

10. Indications of siravyadha :- Same as indications of Raktamokshaņa शोणितावसेकसाध्याश्च ये विकाराः प्रागभिहितास्तेषु चापक्वेष्वन्येषु चानुक्तेषु यथाभ्यासं यथान्यायं च सिरां विध्येत् ॥ ( Su.Sha . 8/4) Other- Hypertension,Pulmonary hypertension ,Acute pulmonary edema ,CCF ,Acute pericarditis,Uraemia (renal failure),Polycythemia vera,Thrombosis .

11. Contraindications of siravyadha :- Bala (child), Jägarita (awakened), Kriša (thin), Garbhinn (pregnant), Klaibya (impotency), Vriddha (elderly), Käsa (cough) , Kshatakshņņa (emaciated), Śväsa ( dyspnoea ), Sosha (emaciation), Ruksha (dryness of body) Pravriddha Jvara (severe fever) Bhiru (feared), äkshepa (convulsions), Parisränta (tired), Pakshāghāta (paralysis), Madyakarshita (emaciated), Upaväsita (fasted), Adhvakarshita (emaciated due to walking), Trishņā (thirstiness), Strikarshita (emaciated due to coitus), Mürccha (fainting), Vamita (who has under gone emesis), Adrishța Siră drishțāśca (visibility of non-visible veins), Virikta (who has undergone purgation), Drishțāśca Ayantrită (not properly tied veins), Asthäpita (who has given decoction enema), Yantritäśca Anutthitä ( undistended veins), Anuväsita (who has given oil enema)

12. Reasons for contra- indications:- Sirävyadha should not be done in Bäla and Vriddha as the Dhatu are ill formed and undernourished respectively. In nervous person-if vyadhana is done there are every chance of that person to meet Sosha . • In Anuväsita , Agni is decreased, so by Sirävyadha it will further decreases. In impotents and the persons affected with Käsa , Śväsa , Sosha , hyperpyrexia, convulsions, fasting, and thirst. In all the strength is very less, hence Sirävyadha may further worsen the condition. Sirävyadha in the persons who have undergone Vamana , Niruha Basti , Madyapana , not slept at night, Pakshägäta causes aggravation of Vata .

13. वातदाह , पाददाह , वातकंटक , विसर्प , वातरक्त – 2angul above kshipra marma जलोदर – 4angul bellow and lateral of umbilicus Grudhrasi – 4 angul bellow or above janusandhi यकृत रोग – karpur sandhi नासा रोग – nasal vein कर्ण रोग – above the karna Shastra used for siravyadha :- Kutharika - siras located on bone Vrihimukha - for sira which hidden &in muscular area. काल :- Acc. To शारंधर –best काल is शरद ऋतू ( 15 augest to 15 october ),best tome is after noon.( After dig. Of food taken in morning) Siravyadh should not perform in extreme hot or extreme cold climate and in cloudy. Generally pitta dosha is get vitiated in शरद ऋतू so, रक्तमोक्षण should carried during this ऋतूकाल

14. Procedure of siravyadha Purvakarma : 1.Sambhära Sangraha (collection of necessary materials) 2. Atura Cayana (Selection of patient)
3. Atura Siddhata (Preparation of patient) Pradhankarma : 1.Sirävyadhanärtha asana (Positioning the patient) 2. Sirävyadha & Nirikshana (Puncturing of vein &observation) 3. Samyak Yoga- Ayoga - Atiyoga Lakshana of Sirivyadha :
4. Vyäpad & Cikitsa (Complications & their management )

15. Purvakarma Sambhära Sangraha (collection of necessary materials):- They are proper place (atmosphere of room where Sirävyadha would be carried out should be pleasant), water container, hot water, cold water, gauze piece, swabs, bandages, Sirä Bandhana materials (thick cloth, tourniquet etc.), sphygmomanometer, kidney trays, marking glass beaker, scalp vein (No. 20), Kutharika Sastra, Vrihimukha Sastra, oil (for Snehana ), cotton pad (for hot fomentation), Näni Svedana Yantra or Bäshpa Svedana Yantra , washing materials (spirit, Pancavalkala Kvätha etc.), chairs, dressing table; Sandhäna , Skandhana , Päcana and Dahana Upakaraņa etc.

16. Rakta stambhak dravyas - lodhra,priyangu,gairika,rasanjana,godhum,arjuna & irimeda Raktapravahaka dravyas - ela,vidang,chitrak,marich,pippali & arka Raktapachaka,kshoumavastra (silk) For स्नेहन - पंचातिक्त घृत , महातिक्त घृत For स्वेदन – नाडीस्वेद & बाष्पस्वेदयंत्र 2. Ātura Cayana (selection of patient): The surgeon according to his experience ( Yathābhyāsa ) consider the disease as well as patient for selection. Raktamokshana should be done according to the procedures ( Yathānyāya ). Routine blood investigations, blood group, blood sugar etc. should be carried out as pre-operative assessment of the patient.

17. 3. Ätura Siddhată ( preparation of patient): Snehana internally for 2-3 days and then Abhyanga & Svedana to the affected part or to the whole body should be done on the day of Sirävyadha . Yavägu which does not aggravate Dosha but pacifies the Dosha should be given just before the Sirävyadha in order to prevent mürecha , bhrama etc.

18. Pradhan Karma 1.Sirävyadhanärtha āsana ( positioning of patient): Acărya Suśruta has mentioned different position of patients in different diseases for Sirävyadha . For head- First Abhyanga and Svedana should be done. Afterwards he should be made to sit on a soft stool of the height of the knee, placing his elbows on his knees, placing the feet together comfortably on the floor and facing the sun. At the level of the lower border of the hairs of the head, a tight bandage should be tied making use of moist cloth, leather or inner bark of the tree. The patient should then be asked to keep the thumbs inside his fists, cover them with cloth and clench them as hard as he can, accompanied with biting the teeth as hard as possible, inflating his mouth. Another person standing behind the patient should put a long piece of cloth around the neck of the patient, make a knot over the nape of patient’s neck, insert the index finger of his left hand into the knot, twist the knot to tighten the knot around the neck taking care not to block the respiration. This will be the method to control and raise the veins of head which are facing inwards (in other words placed deep underneath the skin) and which are forbidden

19. For lower limbs -For puncturing the leg veins, leg should be well placed straight on an even surface, while the other leg is slightly flexed and held at a higher level than the leg to be venepunctured . Cloth ( Yantraņa śataka ) should be tied above the janu . For upper limbs -the hand should be made fist & cloth should be tied above the kurpara Strangling with the cloth, clenching the fist, grinding the jaws, inflating the mouth, tapping on the vein are all meant to raise the pressure inside the veins.

20. 2. Sirāvyadhana & Nirikshaņa ( puncturing of vein and observation): The physician should raise the vein by tapping on it with his middle finger triggered by the thumb. On finding that the vein has risen up and full on touch, he should hold the Kuthärikä (axe) with his left hand keeping its handle up, place it on the vein, tap it with his middle finger triggered by the thumb or press it with the middle of the thumb. At places where the vein is hidden or the skin is thick, pressing with the thumb should be done. Vyadhan pramana ( size of puncture):- In muscular areas, puncturing should be equal to the size of the Yava (barley grain) in other areas it should 1/2 Yava or one Vrihi (rice) using a Vrihimukha śastra . Veins on the bones should be punctured to the size of of Yava using a Kuthärikā śastra After puncturing the vein, vitiated Rakta may flow out in inadequate quantity ( Hina Srava ), proper quantity ( Samyak Srăva ) and more in quantity with Jiva Rakta ( Ati Srava ). Further Samyak Sräva can be divided into Pravara śuddhi , Madhyama śuddhi and Huna śuddhi according to the symptoms obtained by proper puncturing.

21. Maximum limit of bloodletting in a strong adult person with excessively vitiated dosha = 1prastha In this regard nalhaņa advised that blood should be let out in order of 1 Prastha (768 ml), 1/2Prastha (384 ml) and 1/4 th Prastha (192 ml) for Uttama , Madhyama & Hinna Matră respectively.

22. 3.Samyak vyadha Lakshana : When Sirävyadha is done properly then the blood will flow in a stream and after one muhūrta it will automatically stop without any measures. The vitiated blood flows in the beginning from the punctured vein just as yellow juice oozes out of the flowers of kusumbha . Samyak Vyadha Lakshanas are:- सम्यग्गत्वा यदा रक्तं स्वयमेवावतिष्ठते । शुद्धं तदा विजानीयात् सम्यग्विस्त्रावितं च तत् ।। लाघवं वेदनाशान्तिव्यीघेर्वेगपरिक्षयः । सम्यग्विस्त्राविते लिङ्गं प्रसादो मनसस्तथा ।। (Su.Su.14/32-33) लाघवं -Feeling of lightness of the body, वेदनाशान्ति -mitigation of suffering. व्यीघेर्वेगपरिक्षयः -subsiding of severity of the disease. मन प्रसादो -cheerfulness of mind Are the symptoms of proper siravyadh . -The persons who are debilitated, who have great accumulation of Dosha or who are afflicted by fainting. Sirävyadha should be done in the afternoon or on the next day or on the third day (Su.śā.8/9).

23. Complication of Sirăvyadha and their management with ayurveda and modern medicines : At the time of Sirivyadha the complications are produced either due to Durvidda or due to Atividda . One of the major complications which may leads to death is murccha ( unconsciousness). If patient become unconscious while performing Siråvyadha , the following points should be considered – -Immediate removal of the instrument from the wound.
-Cold water sprinkling over face
-Consolation and assurance to the patient. -Further Sirävyadha after the management of unconsciousness.
-Proper ventilation and aeration.
-If the unconscious reappears then Sirävyadha should be done after 2-3 days.

24. Causes of ayoga / हिन स्राव and its management Sirävyadha , if done on cloudy day, if the puncturing is improper, if affected with cold and breeze, if sudation is not done earlier and if done after meals causes the vitiated Rakta does not flow out properly or flows out in little quantity. In persons suffering from intoxication, fainting, and exertion, who have suppressed the urges of flatus, faeces and urine;who are in the grip of sleep and fear, blood does not flow out Also in the persons who have fainted, greatly afraid, exhausted or thirsty vitiated Rakta does not flow out when vein is punctured as well as when vein is not raised by Yantraņa .

25. Treatment of hinasrava :- Ela , Kustha , Tagara , Patha , Bhadradaru , Vidanga , Chitraka , Trikatu , Aagaradhuma , Haridra,kushta,pippali,marich , Arkankura either three, four or as many as available of these drugs should be powdered, mixed with a large quantity of salt and oil, should be rubbed on the mouth of the wound; in this way vitiated Rakta flows out properly.

26. Causes of atiyoga and its management Siravyadha if done during the excess heat (in summer), if sudation has been done in excess, if the puncturing is very much and if done by the ignorant (unskilled or inexperienced) then the blood flows out in excessive quantity. This causes- Shiroroga (headache), andhata (blindness), Adhimantha (Glaucoma), Timira (cataract), Dhātukshaya ( depletion of dhatu ), Aksepaka (convulsions), pakshaghat ( paralysis), daha (burning sensation), Ekangaghata (hemiplegia), truahna ( thurst ), hikka (hiccough), swasa ( dyspnoea ), kasa ( cough), pandu ( anaemia ) and marana (at last in extreme cases Death may occur).

27. Treatment of atisrava :- चतुर्विधं यदेतद्धि रुधिरस्यनिवारणम् । संघानं स्कन्दनं चैव पाचनं दहनं तथा ।। व्रणं कषायः संधत्ते रक्तं स्कन्दयते हिमम् । तथा संपाचयेद्भस्म दाहः संकोचयेत् सिराः ।। ( Su.Su . 14/39-40) In Raktasrava , sthambhana is achieved by four methods ie . Sandhana , skandhana , pachana and dahana .
(a) Skandhana : The above said Rakta Skandhana drugs like Lodhra etc , are sprinkled over the site of Vyadhana . It does Skandhana by binding to the site of Vyadhana .
(b) Sandhana : If the above measures fails, then the above said Kakolyadi Gana Kashayas are poured over the Bandhita site of Vyadhana . It helps in coagulation of Rakta .
(c) Pachana : If the above measure fails then the Kshouma Vastra Bhasma is sprinkled over the site of Vyadhana .
(d) Dahana : If the above measure fails then Dahana of the Vyadhita site is carried with the help of Guda , Sneha or honey.

28. When the blood flows out excessively powder of rodhra,madhuka,priyangu,patanga,gairika,sarjarasa,salmali pushpa,Šankha , Šukti , Mäsha , Yava and Godhüma should be sprinkled and pressed with the tip of the finger on the wound; Or churna of bark of sala,sarja , arjuna,animeda,meshasrungi,dhava and dhanvana;Or ash of kshauma ; Or powder of samudraphena and laksha may be sprinkled; then bandage is tied tightly using any bandaging material mentioned. The patient should be covered with moist cloth, put in a cold room, treated with application of poultices and pouring liquids in cold condition; or the area may be burnt (cauterized) either with Kshära or Agnikarma . Modern management:- in case of excessive bleeding – ligation of punctured vein,hemostatic drugs and if needed blood transfusion.

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