Rakthamokshana karma

Sri lankan Ayurvedic presentation

1. Rakthamokshana Karma (Blood letting) Presented by DR. DKR.KEERTHI RATHNA DR.GGTD. DE SILVA DR.WR.PREETHI SURANGANIE DR.MFM.SHILMY SRI LANKA

2. Objectives To define the rakthamokshana karma To describe the types of rakthamokshana karma To describe the mechanism, procedure and clinical usage of leech therapy To indicate the complication of leech therapy

3. Introduction Bloodletting has a long, venerable history of use in traditional and pre-scientific medicine. It is still used in alternative medicine as part of Unani , Ayurveda , and traditional Chinese medicine . It is one of pancakarma therapy which belong to the shodhana karma of Ayurvedic treatment.

4. Definition of Rakthamokshana The word ‘ Rakta ’ means: रक्त - coloured , dyed, tinged, painted, Red, crimson, blood red. Mokshana : मोक्षण The word ‘ Mokshana ’ is derived from the root ‘ moksha ’ means ‘to relieve’ or ‘to let out’. Therefore letting out of blood is known as Raktamokshana .

5. Normal blood प्रसन्न वर्णेन्द्रियं इन्द्रियार्था निच्छन्तमव्याहत पक्तृवेगम् । सुखान्वितं पुष्टिबलोपपन्नं विशुद्धरक्तं पुरुषं वदन्ति ॥५३॥ Excellence of color and complexion, improved power of the sense organs, good perception of objects by sense organs, good digestive activity, enjoyment of comforts endowed with good nutrition and immunity- are the characteristics of the person having non vitiated blood.

6. Dushtarakta Lakshana ( characteristics  of impure blood) Blood vitiated by Vata , will be blue or crimson in color, dry- nonslimy , flows  with force, clear and frothy . Blood vitiated by pitta will be yellow or black, has foul smell, not thick because of increase of heat and mixed with glistening particles. Blood vitiated by Kapha  will be unctuous, pale -yellowish- white in color, has  small threads, is slimy and thick. By combination of 2 Doshas , there will be mixed features. Blood vitiated by all the Doshas will be dirty and thick.

7. Historical background of blood letting

8. Historical background of blood letting ….. bloodletting technique Sravana being described in approximately the 6th or 7th century B.C. in the Ayurvedic surgery. Greek humorism (black bile, yellow bile, blood, and phlegm) spread, gradually became Europe's chief medical practice. And arrived in Asia, where it was adopted by Islamic cultures and adapted in the form of Unani in about the 10 th century A.D.] Avicenna was a proponent of Unani . Today, the term phlebotomy refers to the drawing of blood for hemochromatosis , polycythemia vera , porphyria cutanea tarda .

9. Ancient instrument for blood letting Leeches sharpened sticks, shark’s teeth, knives. Scarificators The "superficial" vessels were attacked, a springloaded lancet , or a glass cup that contained heated air, producing a vacuum within.

10. Ancient instrument for blood letting.. Lancets

11. Lancets…. Interior of spring lancets

12. Cupping instrument   Once a scarificator was used to slice and dice the patient, a cup was often placed over the wound as a receptacle for the blood. Cups were made of tin, brass, rubber, horn, and most commonly glass.

13. Types of Raktha Mokshana

14. Types of raktamokshana 01. Pracchana Multiple incisions are made with Scalp blade, vertically & parallel to the course of local blood vessels at the desired site.

15. 2. Siravyadha Siravyadha is done with sharp instrument and as such it is a more severe form of blood – letting. Indications : The bad blood causes abscess, enlargement of the spleen and liver ,loss of appetite, fever, disease of mouth, eye and head, Vericose vein, loss of consciousness.

16. CONTRAINDICATIONS बाल , व्रुद्ध् , गरभिणि , सूतिक – अस्निग्ध , अतिस्निग्ध अस्वेदित , अतिस्वेदित अजीर्ण , अतिसार , च्छर्दि पित्तास्र , पाण्डु , श्वास , कासा महोदर , सर्वाङ्ग शोफ़ स्नेहपीत , पञ्चकर्म ( Su.su 14/28, Su Sa. 8/3)

17. Siravyadhanapoorvakarma : Snehana karma – consume meat-juice and boiled rice mixed with ghee, Sweda karma - niragni sweda ( eg : sun light, heat with a light, fire etc.) Tied a band above the veins Should tap the raised vein with physician’s middle finger tripped off by the thumb;

18. Pradhana karma The lancets ( shastra ) is incerted quickly neither too deep nor superficial in the middle of the vein without injuring the marma points The maximum quantity of blood that may be let out should not exceed one prastha

19. Siravyadha ….. Paschat karma: apply spirit Fine powder of haridra and laksha to the site of blood letting Samsarjena karma followed.

20. Action of siravyadha : Choice of treatment in Pitta  and Rakta Reduces intravascular pressure and volume which will reduce pain and swelling Reduce the breakage of RBC, in turn reduces pigmentation and itching.

21. 3. Rakthamokshana by suchi Charaka has indicated suchi blood letting . Most probably he means that blood letting should be donne by needling and made to ooze out the blood from the site of blood

22. Anushastravishravana Jaluka - Pitta Shringa - Vata Alabu - Kapha Alabu

23. Alabu creating vacuum and extracting blood through the vacuum using a bottle guard or Alabu ; Pungent, rough Medium sized alabu selected. Dried in hot sun Round hole is made at the bottom and contents emptied. Procedure: Incisions is made on the skin Leaf is placed near the incision Candle is placed on the leaf and ignited Covered with bottom of alabuyantra Vacuum is created in alabu and blood rushes out.

24. Shrungavacharana scratching the site, blood letting should be done by means of the cow horn to which piece of thin urinary bladder (of an animal) has been tide as a cover by a thread , till blood is sucked out by manual mouth suction.

25. Shrungavacharana …

26. Jalaukavacharana (Leech therapy) It is considered as most unique and most effective method of bloodletting. It is safely indicated in all mankind including the patients having poor threshold to pain In Ayurveda and Sri Lankan traditional medicine, in bloodletting therapy through leeches, purified and cleaned medicinal leeches are applied in management of various disorders, especially which are caused due to vitiation of pitta and rakta dosha .

27. Jalauka जलमासामायुरिति जलायुकाःजलमासामोकइति जलौकसः II (Su S 13/9) Since jala is their life, they are called as Jaluka or since they are habituated to water they are called as Jalooka .  

28. Jalauka …. Scientific classification : Kingdom                    : Animalia Phylum                      : Annelida Class                          : Clitellata Order                        : Hirudinea Family                       : Hirudidae Binomial name       : Hirudomedicinalis

29. Types of leeches Poisonous leeches Non- poisonous leeches KapilaKrishna Pingala Karbura Kapila Alagarda Pundarikhi Indrayudha Savarika Saamudrika Mushika Gochandana Shankamuki

30. Indications of leech therapy ( jalaukavacharana ) Diseases Charaka Susrutha Vagbhata 1 Skin diseases( Kushtha) + + + 2 Erysipelas (Visarpa) + + + 3 Boils and carbuncles (pidaka) + + - 4 Abscesses (vidradi) + + + 5 Ring worm (dadru) + - - 6 Scabies (pama) + - - 7 Tumours (arbuda) - + - 8 Eczema ( vicarchika and charmadala ) + - -

31. Other indication of leech therapy Peripheral vasculardiseases Diabetic foot ulcer Non healing ulcer Thrombosed Haemorrhoids Tenosynovitis Vitiligo Warts Foot Corn  

32. Contraindications of leech therapy ( jalaukavacharana ) Absolute Hemophilia Severe Anaemia Erosive gastritis and potential gastrointestinal bleeding During chemotherapy ( or people who are on immunosuppressive medication) Individuals with HIV infection Cachexia (of any cause) Severe allergic diathesis (allergy to foreign proteins) Hypotension Active tuberculosis Pregnancy Mental disorders during acute episodes Severely ill and bed ridden patients Extremely fearful patient

33. Mode of action of hirudotherapy When leeches bite, they create a tunnel to the lymphatic system remove toxins from the lymph system. The main effects of the medicinal leech on the body include: decreased blood clotting thrombolytic (clot destruction) antiischemic (improving blood supply to tissues and organs) antihypoxia (improved blood supply oxygen to the tissues and organs) hypertensive ( normotensive ) draining the blood and lymph system of toxins and blood clots restoration of the microcirculation recovery of neuromuscular impulse transmission restoration of vascular permeability bacteriostatic (death of microorganisms, causing inflammation) immunostimulatory

34. The important constituents present in the leech saliva Hirudin - It is a powerful anticoagulant, it inhibit blood coagulation by preventing conversion of fibrinogen to fibrin. Hyaluronidase - It breaks down the hyaluronic acid. As a “spreading factor”, it opens the interstices, paving the way for other active substances in leech saliva to reach the deeper tissues. Hyaluronidase also possesses antibiotic property. Destabilase - Amonomerizing enzymes that dissolves fibrin Eglins - Are anti-inflammatory proteins. They inhibit the activity of alpha- chymotrypsin , chymase , subtilisin , and the neutrophilic proteinase elastase and cathepsin G. Calin - Inhibits blood coagulation

35. The important constituents preesent in the leech saliva … Bdellins - Anti-inflammatory, inhibits trypsin , plasmin , and acrosin . Acetylcholine - Vasodilator Histamine like substance - Vasodilator Carboxypeptidase A inhibitor - Increases the inflow of blood at the site of bite.

36. Collection should be kept in a bottle with broad lid filled with water. Feed them with powder of dried meat and aquatic bulbs leaves of water plants The water should be changed every third day and feed should be dropped

37. Materials required TURMERIC POWDER COTTON COTTON

38. Purva Karma (Before procedure) the patient should be subjected to snehana ( oleation ) and swedana (fomentation), to enhance the mobility of dosha Fresh leeches should be taken, and a mixture of mustard and turmeric paste in water should be applied upon them.

39. Pradhana karma The patient should be made to sit or lie down The leeches should be hold at its neck and should be applied directly to the affected part. They should be covered with wet cotton and cold water should be poured on them from above time to time

40. Paschata karma (after procedure) The site should be cleaned with normal saline and bandaging should be done after sprinkling turmeric powder with beehoney to the bleeding site. After falling off, the leeches should be made to vomit. This is carried out by applying turmeric powder at their mouths. When the blood comes from the anterior sucker, gentle squeezing from caudal to front end is required for proper emesis If the leech is active when placed in water, it indicates that the vomiting is proper.

41. The leeches should be made to vomit,applying turmeric powder at leeches’s mouths.

42. bandaging should be done after sprinkling turmeric powder to the bleeding site.

43. Complications of leech therapy The bleeding was not controlled by applying pressure with sterile gauze upon the wounds. Allergy to leech bites, even severe allergic or anaphylactic reactions has been reported .

44. Research findings on Rakthamokshana 1. Raut S.Y, Rasale P.L et.al study found that there is no effect on sirawedha on RBC indices. 2. Motial .R and Shrilata K. study found that, the combination of sarivadyasava and jalaukavacharana showed a statistically highly significant response in reducing the symptoms and signs of Yuvanapidaka . 3.Weinfeld AB and Yuksel E et.al study reveal that the Leech therapy has been proven to help patients suffering from venous diseases 4. Bapat RD and Acharya BS et.al mention that medicinal leech is effective in the management of complicated varicose veins, it heals ulcer, decreases the oedema and limb girth, and decreases hyperpigmentation .

45. Research findings on Rakthamokshana … 5. Dwivedi , A. P study found that applying leeches on diabetic foot ulcer , Leech therapy improve the blood circulation and reduce the congestion due to presence of Carboxypeptidase . Leech application has anti-inflammatory action nerves due to presence of substance like Bdellin and Eglins in saliva, hence correct diabetic neuropathy 6. A single course of leech therapy was effective in relieving pain in the shortterm in patients suffering from chronic lateral epicondylitis (Tennis elbow) and reduced disability in intermediate-term.

46. Referances   Sathish H.S., Baghel M.S., Bhuyan C., Vaghela D.,B.., Narmada M.,G., Mithun B., , Outline of researches on raktamokshana,11/09/2013 SushrutaSamhita – Ayurveda tattvasandipika commentary by DrAmbikaDattaShastri , sutra sthana published by Chaukhambhasamskritsamsthan , Varanasi; p. 43-46. Vidyalankara.A , Ayurveda BrihatItihas.1st Ed. Varanasi; BhargavaBhushana Press; 1960.p. 127. " Leeching".Encyclopaedia Britannica.Encyclopaedia Britannica Online.Encyclopaedia Britannica Inc 2013.Web.05<http://www.britannica.com/EBchecked/topic/750132/leeching>. Textbook of Natural Medicine , Barnes & Noble, available on www.barnesand noble .com/w/text book-of-natural-medicine- joseph -e- pizzorno /1100325443 Naturopathy Embraces the Four Humors , Jann Bellamy, Science-Based Medicine , available on,science based medicine .org/index.php/naturopathy-embraces-the four-humors/

47. Charakasamhitha , (2015), Ayurveda –e- samhitha , chikitsastana , kalpa 1-4 , Available at ayurveda pg.com/ charak % 20 samhitha /7. Charak _ kalpa.pdf Pancakarmatherapy in Ayurveda by DivakarOja   Elsytta MJ Sreedhareeyam , rakthamokshana in nethra , ayurvedic eye hospital and research centrekoothattukulamEmail:[email protected]   Linda M. Johnson (2011) ayurvedic treatments, © 2011 Srikanthamurthy K.R., (2004), AshtangaHrdayam – English translation text, ChowkhambaKrishnadasa Academy Varanasi, Vol. 01, 27-53, pp.317

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