Leech & Blood Letting Therapy

1. Dr.Amar P. Dwivedi M.S. (Ayu.) Ph.D.(Sch.) Associate professor & I/C, Shalya Tantra Dept. Dr.D.Y.Patil College of Ayurved, Nerul, Navi Mumbai Email: dramar_d@yahoo.co.in dramar.sarc@gmail.com Website: www.amarayurved.com Leech & Blood Letting Therapy

2. Ayurved & its Basic Principles : According to Ayurved, our body is formed by the combination of Dosha (Vata, Pitta & Kapha) , Dhatu (Sapta Dhatu viz. Ras, Rakta, Mans, Meda, Ashthi, Majja, Shukra) & Mala (Purish, Mutra, Swed). All the constitute or tissues of the body contains all the three i.e. Dosha, Dhatu & Mala in subtle amount. Out of these Tridoshas are considered more important as they form a base in nourishment & development of the body. Whenever there is disequilibrium of Doshas occurring, it directly affects the health & pathology is introduced. Hence, basic Ayurvedic treatment is based on two principles : 1.Shodhan chikitsa: (Elimination Therapy) Elimination of excess doshas from the body is known as Shodhan chikitsa. 2. Shaman chikitsa: (Palliative or Internal medicine) When the increased Doshas are brought into equilibrium with the help of Herbo-mineral medicines, the therapy is known as Shaman chikitsa. However, out of the two therapies, ‘Shodhan chikitsa’ has great importance.

3. According to the Ayurvedic texts it is said, as applying colour on dirty clothes won’t help in attaining bright/ good colour (the clothes must be washed prior to re-colouring).Similarly, when Ayurvedic treatment is given, specially in chronic diseases or metabolic disorders, Shodhan chikitsa has to be done before giving any palliative medicines so as to achieve good results or prognosis. • In other words, for treating chronic diseases, the patient has to undergo Panchkarma (five fold eliminating measures) i.e. Shodhan , after which it become more easy to treat the disease. • The five Purificatory procedures advocated are: • a.Vaman karm • b.Virechan karm • c.Basti karm • d.Nasya or Shiro-virechan • e.Raktamokshan

4. Raktamokshan (Blood Letting Therapy): • Expulsion or removal of vitiated blood from the body is known as Raktamokshan. • This can be done either through the prominent superficial veins with the help of simple scalp- vein canula (Sira-vedh), with the help of Leech Jalokavacharan), by taking multiple Incisions on a particular site (Prachhan karma), by sucking blood with the help of animal horn (Shring) from the site where prior incision is taken or removing blood with the help of empty dried bottle gourd (Alabu). • Importance of Raktmokshan • Raktamokshan or Blood letting is given prime importance in Panchkarma or Shodhan chikitsa. It is said that a number of diseases which are otherwise incurable can easily & effectively be cured only by Raktamokshan alone. • As the advocates of ‘Kayachiktsa’ believe ‘Basti or Medicated enema’ to be ‘Sarva- rog nivarini’ & thus 100% of the treatment is occupies by ‘Basti karma’. Similarly, Raktamokshan by ‘Sira- vedh’ i.e. vene puncture occupies such a place in ‘Shalya tantra’. • It can be said that half or rather entire Shalya Tantra is equivalent to ‘Sira-vyadh’ alone i.e. a number of diseases are likely to be cured only through this simplest technique.

5. Effect of Raktamokshan • Rakta, the blood being the vehicle to carry & transport absorbed nutrients, oxygen, metabolites etc. from place to place. So, correction of any abnormality in the blood by taking it out, solves a number of problems. • Also, those who get ‘Raktamokshan’ regularly as a routine, never suffers from Twak dosha (various skin problems), Granthi (cyst, tumours), Shoph (inflamation) and Raktaj roga (Kushtha, Nilika) etc. such is the miraculous effect of Raktamokshan . • Acharya Sushrut further says that, this is the only therapy which helps in eliminating all the three vitiated doshas (Vata, Pitta & Kapha) at a time. He further advocate that if all the five-fold purificatory procedure can not be performed due to lack of time then, even ‘Raktamokshan’ can serve the purpose.

6. Types of Raktamokshan The Raktmokshan or Blood letting is done mainly in 2 forms- 1.Sashastra i.e. with instruments & 2.Ashastra i.e. without any cutting instrument 1.Sashastra Raktamokshan- This is done with the help of surgical blade. An incision is made at the desirable site followed by removal of blood by means of sucking. Depending upon This is further sub-divided into 4 types: a)Prachhan karm= Blood letting through multiple incision b)Alabu = Vacuum extraction by using ‘bottle gourd’ c)Shring = Sucking by mouth through animal horn d)Sira vedh = Vene puncture 2.Ashastra Raktamokshan- In this,the vitiatedblood is taken out or removedonly by means of Leech application. Hence, we can say that this is done without using any cutting instruments.

7. Raktamokshan with the help of ‘Prachhan karm’ In this procedure, without injuring the Joint capsule, Tendons, Bones & Marma- sthana (vital points) multiple incisions are made with ‘Utpal patra sashtra’ i.e. Scalp blade, vertically & parallel to the course of local blood vessels at the desired site. After the ‘Prahhan karma’ dressing is done with aseptic precaution. Note: If transverse incisions are made under skin then damage to blood vessels can occur. Prachhan karm is useful in conditions like Paraphimosis, Cellulites, Localized collection/ accumulation of fluid under the skin & sub coetaneous tissues, Haematoma, Early stage of Filariasis (Lymph edema), Snake, Scorpion or Insect bite etc. Principle: Following the multiple incisions, the vitiated blood & accumulated doshas comes out of the body. So, we can say that the main purpose of Prachhan karma (by facilitating drainage of blood from the affected site) is to relieve tension or the local pressure. At the same time, this also helps to remove the toxins & other waste products from that site.

9. Raktamokshan with the help of ‘Alabu Yantra’ This is indicated when there is predominance of ‘Kapha dosha’. While there are two openings of ‘Shring Yantra’, there will be only one opening for ‘Alabu Yantra’. Preparation of ‘Alabu Yantra’ Firstly, a medium size ‘Alabu’ or ‘Bottle gourd’ (a kind of vegetable commonly known as Kaddu or Pumpkin) is selected and is allowed to dry in hot sun. After that a one rupee coin sized round hole is made at its bottom and all the interior (contents) are taken out or removed skillfully. Special attention is made to keep the other end of the ‘Alabu’ narrower than the bottom. Procedure : Firstly, small nick (incision) is taken on the skin. Thereafter, immediately a small piece of leaf is placed by the side of the nick. On top of this leaf a small Candle or Deepak is placed and lightened. As the Candle burns up, it is covered with the bottom of ‘Alabu Yantra’. ….cont.

10. Within a few seconds the flame gets extinguished and the patient notices as if the skin is being squeezed into the space of ‘Alabu Yantra’. This is because of the pressure created in the empty space of the ‘Bottle gourd’ which leads to stretching of the area where nick was made, resulting in oozing of blood. Here the skin edges are caught tightly by the margins of ‘Alabu Yantra’ till blood letting is completed. Principle ‘Alabu Yantra’ works on the Bale- Jar’s principle which states that 1/5 th of the atmospheric air contains oxygen and when it is consumed by the flame of a Candle within the container then 1/5 th vacuum will be created. Thus, vacuum is likely to be occupied by whatever fluid or solid that is available at its bottom. Alternative device As a substitute for this, one can use a simple wide mouthed 100 ml tea glass (made of glass). Give a small cut on the skin. Place a burning spirit swab on a small piece of leaf of tin and immediately cover the flame with this glass. In a few seconds, the flame will be extinguished. The skin bulges out into the glass and from its center where the incision is given, blood gushes out like a fountain.

12. Raktamokshan with the help of ‘Shring yantra’ This is indicated when there is predominance of ‘Vata dosha’. ‘Shring yantra’ is a very simple instrument made up of a Cow’s or Bull’s horn with both of its ends open. Procedure: Firstly, 2 or 3 nicks (small incisions) are taken at the desired site with the help of sterile knife or surgical blade. Thereafter, the wide base of the horn is placed on the designated site where the nicks are made and the physician holds the narrower end. The base must exactly fit the site of Raktamokshan. The base of ‘Shring’ must be so nicely cut that air or blood will never leak out while the physician sucks the blood. …..cont.

13. The most convenient method is to suck the air vigorously at a single stream & immediately close the narrow mouth with the thumb or rather with the tip of tongue. With this, vacuum is created within the horn and the blood rushes out in jets from the incision that is given on the skin. After the removal of desired amount of blood, fine turmeric powder is sprinkled over that area followed by proper bandaging which will certainly arrest the excess bleeding. Modified ‘Shring Yantra’ Keeping the principle of vacuum extraction in this ‘Shring yantra’, one can use similar instrument called ‘Breast pump’ or ‘Milk expresser’. In this, instead of sucking through mouth, a rubber bulb can be used.

15. Raktamokshan with the help of ‘Sira-vyadhan’ This can be termed as ‘Vene-puncture’ and is one of the easiest mode of ‘Raktamokshan’. Sushruta gives utmost importance to this technique. Supremacy of ‘Sira Vyadhan’ It is said that half or rather entire Shalya Tantra teatment is equivalent to Sira- Vyadhan chikita (Blood letting by Vene-puncture) alone. The region behind is that this is the only therapy which helps in eliminating all the three vitiated doshas (Vata, Pitta & Kapha) at a time. He further advocate that if all the five-fold purificatory procedure can not be performed due to lack of time then, even ‘Raktamokshan’ can serve the purpose. A number of diseases are likely to be cured only through this simplest technique. Factors to be considered for ‘Sira Vyadhan’ Poorva karma i.e. Preparation of patient & Equipments Indication / Contra indication Pradhan karma i.e. Main procedure Pashchat karma i.e. Arrest of haemorrage

16. Sira-vedha (Poorva karma) Selection of suitable patient Snehan- Swedan (half hour before) at the site of Sira-vedh. Laghu Aahar (Light semi-solid diet) like Yavagu etc. Coagulatory disorder like haemophilia should be rulled out. Similarly, precautionary measures to be taken while handling the Anaemia, Diabetes, Hepatitis, HIV patients. After Mangal & Swasti vachan (prayer) patient is given either supine position or slight propped-up position. Now, a vein is selected for vene- section & a tourniquet or bandage is applied a little above the site of Sira Vyadhan. Time suitable for ‘Sira Vyadhan’ Blood letting by ‘Sira Vyadhan’ is performed preferably in Sharad reetu as Pitta is vitiated more in this season. Better to avoid Grishma reetu (i.e. last 15 days of April, May & first 15 days of June). Ideally, this should be performed in comfortable, cool & pleasant weather.

17. Indications for ‘Shira- Vyadhan’ Useful in various skin diseases like skin eruptions, boils, any type of oedema or inflammation, cellulites, erysipelus, lymphadenitis, tumors, cysts etc. Raktaj roga i.e. blood borne diseases like Visarpa (erysipelas), Pleeha (spleenomegaly), Vidradhi (Abscess), Kushtha (Leprosy, or Leucoderma ), Pandu (Anaemia ? Heamopoetic disorder), Kamala (Jaundice), Gulm, Upkush (Pyorrhea alveolaris), Nyachcha- Tilkalak- Vyangya (Mole or Warts). Also it is useful in Hypertension, Eczema, Psoriasis, Obesity, Toxaemia, Various vascular disorders, Non- healing ulcer & Filarial conditions. Note: It is advocated that those who undergoes ‘Blood letting’ procedure regularly, will not suffer from the above Skin diseases or blood borne diseases. Ideally, even if a person donates his blood once in a year, he will be equally benefited.

18. Contra- indication of ‘Shira- Vyadhan’ Blood letting should not be done in following condition: Very young children & very old people Ruksha/ Kshat/ Ksheen/ Krish– extremely weak, under- nourished & debilitated patients. Bheeru i.e. Timid person Parishrant i.e. Highly exhausted person Stree karshit i.e. Excessive sex indulgence After Vaman, Virechan & Basti karma In Insomnia & Sleeplessness conditions Pregnant womensss Kleeb i.e Impotent Anaemic & Haemophilic Patient Patients suffering from Cough, Breathlessness, Muscular wasting, High grade fever, Convulsive disorders, Paralysis, Giddiness & patients who are Fasting or Thirsty.

19. Instruments or Material Used: In Sushrut samhita, various modalities are advocated for the purpose of ‘Sira- Vyadhan’ depending upon condition & location of the vein. They are: 1.Brihee- mukh Shastra : When the vein is located in a fleshy area, the Sira- vyadhan is done with the help of ‘Trochar & canula’ i.e. Brihee- mukh Shastra. Even Vein flow, Intra- cath or Scalp vein can be used for the purpose. In day to day practice Scalp vein no. 18 to 20 is more often used.The other modalities given are: 2.Kutharika Shastra- When vein is crossing bone 3.Vetas Patra- When vein is fine 4.Aara Shastra- When vein is big & large amount of blood has to be removed.

20. Pradhan karma(Main Procedure) After applying tourniquet, a prominent vein is selected and punctured with the instrument i.e. scalp vein & is fixed with the help of sticking / adhesive plaster. Usually, a B.P. calf is applied on the opposite arm & pressure is maintained around 80 mm/Hg. Blood immediately starts flowing out through the IV canula which is collected in a measuring pot. After certain duration, the blood letting slows down & spontaneous arrest of haemorrhage takes place, which is an indication of proper or adequate blood letting. Practically, on an average around 80 to 120 ml of blood letting is expected. But, this can vary depending on nature of disease & vitiated Doshas. Note: In text, max. amount of blood letting allowed is 13.5 pal. (as 1 pal= 50 gm, therefore total amount will be up to 0.75 lit.)

21. Sira-vedhan (Pashchat karma) After the desired amount of blood is drained out, the scalp vein is removed & pressure is applied with spirit swab followed by bandaging. Even Haridra + Laksha fine powder can be sprinkled prior to dressing, so as to achieve haemostasis. After ‘Shira- Vyadhan’ or Vene puncture, patient is asked to have light diet or he is advised to follow the ‘Sansarjan- kram’. If patient feels thirsty or giddy, then cold water is sprinkled on his/ her face. Also, Lime water, Soup or Glucose water can be given to the patient. In such conditions, patient is retained in the procedure room till he feels comfortable. Rule for selection of site: Blood letting should be done from the peripheral or the nearest vessel from the affected site. Generally, for sarvadehik Shodhan- median cubital vein is preferred.

22. Causes of failure of ‘Shira- Vyadhan’: Faulty technique Collapse of vein due to ‘Shock’ Low BP/ Obesity/ Anxiety neurosis Over exertion Extreme weakness Dehydration Fear Loosening of tourniquet Blunt instrument ‘Shira- Vyadhan’ done without prior Fomentation In Text books, this is further divided according to Shastra- dosh, Rogi- dosh, Yantra- dosh, Sira- dosh & Vaidya- dosh. Sign of Proper or Adequate Blood letting: Laghav- Feeling of lightness Vedana shanti – Relief from pain Vyadhi weg parikshay- Arresting further progress of disease Manh prasad- Feeling of wellbeing Raktum Swayamev Avatishthhate- Haemostasis by its own Shuddha i.e. Fresh/ purified/ clear blood is seen at the end

23. Sign of Excessive/ Over Blood letting: Sirobhitap- Headache with warmness Aandhyam -Blurring of vision Adhimanth- Glaucoma Timir pradurbhav- Errors of refraction Dhatu kshay- Loss of tissue (Emaciation) Aakshepak-Convulsive disorder Daah- Burning sensation Pakshaghat- Hemiplegia or Monoplegia Hikka- Hiccup Swash, Kaas- Dysponea, Coughing Pandurog- Anaemia Maran- Death

25. Raktamokshan with the help of ‘Jaloka’ In this method, Raktamokshan is done with the help of ‘Leeches’ i.e. Leeches are applied on the desired site for blood letting. It is considered most unique & most effective method of blood letting. Here, the vitiated ‘Doshas’ are removed from the body without using any cutting instruments, hence Raktamokshan by means of ‘Leech’ comes under ‘Ashastra’ category. Definition of ‘Jaloka’ As the very basis of life for ‘Leeches’ is water, since their site of dwelling is ‘Jal’ i.e. water, the ‘Leeches’ are known as ‘Jaloka’.

26. Types of Jaloka Broadly Jalokas’ are divided into two types- - Poisonous (Savish Jaloka) - Non- poisonous (Nirvish Jaloka ) Six different types of Leeches are found in both poisonous & non- poisonous category. Basically, these Jalokas are named according to their appearance i.e. their external look or colour. Poisonous Non- poisonous Krishna Kapila Karbura Pingala Alagarda Shankh- mukhi Saamudrika Mushika Indra- yudha Pundarik- mukhi Go chandana Saa varika

27. Identification of Non- poisonous Leech The Non- poisonous or ‘Nirvish Jalokas’ can br safely identified by their = Yellowish- Manhshila-like colour, = their swift activity or = by their glitter like or copper like colour, = by their wide lotus- bud like mouth & = by their glistening appearance. Generally, these Leeches are grown in pure flowing water, ponds withclean water & the lakes in which there are lotus flowers & greenery. Note: The poisonous Leeches are found in Muddy water, Gutters or in water which is contaminated by urine, stool, fish, frog & other water animals. They are comparatively bigger in size & dark in colour. After the application they produce severe pain, itching or allergic reaction at the site, giddiness, fever, burning sensation, vomiting. Also few patient may develop signs of intoxication & sinking.

28. About Leeches Scientific name: Hirudo medicinalis Country: Albania, Armenia, Austria, Azerbaijan, Belarus, Belgium, Bulgaria, Czech Republic, Denmark, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Ireland, Italy, Kazakhstan, Latvia, Lithuania, Luxembourg, Moldova, Netherlands, Norway, Poland, Portugal, Romania, Russia, Spain, Sweden, Switzerland, Turkey, Ukraine, United Kingdom, Yugoslavia Continent: Europe, Asia Diet: Blood of birds, fish, frogs, mammals Food & feeding: Carnivore Habitats: Freshwater Conservation Status: Near Threatened Relatives: Earthworm, lugworm

29. Description: Leeches have segmented bodies like an earthworm, but unlike earthworms they are slightly flattened rather than round. They have a sucker at the head and the tail end and the one at the head surrounds the mouth. The mouth contains three jaws that can break the skin of their hosts to suck their blood. Medicinal leeches are greenish brown on their backs with thin red stripes running along the body and paler below. They grow up to 20 cm in length. Lifestyle: Leeches live in shallow muddy pools and ponds with plenty of waterweeds. When hungry, they attach themselves to a passing animal, break the skin with their jaws, and inject special chemicals that prevent the blood from clotting and reduces any pain. They then suck the blood of the host until they are full, when they withdraw their jaws and drop off into the water. They can consume 15 grams of blood - ten times their own body weight, before they are full, but they only need to feed every six months. Family & friends: Like slugs, leeches are hermaphrodite, having both male and female parts, but they still need to come together to mate with each other. Growing up: After mating, 15-50 eggs are laid in a spongy case or cocoon, above the waterline often under stones. The eggs hatch in 3-5 weeks and the young leeches need two seasons of feeding before they are ready to breed themselves. About Leeches

30. Materials and equipments for leech therapy Ideally a seprate leech threapy room is prefered. This room should be well equiped with Pateint bed, Separate tanks for storage of leech, The dressing trolly having gloves, gauze pieces, Normal saline , blood pressure instrument, emergency medicines like Atropine, Hydrocortisone, Adrenaline, Ethamsyl, Avil, IV Fluids etc. to combat reactions if any. Adequate number of sterile tray for cleansing of leech, cleansing material like turmeric powder etc. dressing materials

31. Leech Therapy Room

32. Jaloka Sangrahan (storage)

33. Materials and Equipments

34. Purva karma: Preparation of patient Selection of suitable patient Laghu Aahar (Light semi-solid diet) like Yavagu etc is advocated before the procedure Coagulatory disorder like haemophilia should be rulled out. Similarly, recautionary measures should be taken while handling the Anaemia, Diabetes, Hepatitis, HIV patients. No Snehan i.e. oleation should be allowed. However,Mild Swedan (half hour before) to the site of blood letting can be given. The desired site is properly washed with cold water. (One should not apply Spirit gauze or turmeric to clean the area in any condition.) After Mangal & Swasti vachan (prayer) patient is given either supine position or slight propped-up position.

35. Preparation of patient (Cleaning & Marking)

36. Preparation of Jaloka Fresh Leech from the tank/ jar is chosen & dropped in a tray or bowl filled with clean water. Fine turmeric & trifala powder is mixed in it. One can observe that an inactive Leech becomes highly active & runs all around the tray immediately after sprinkling of the powder which indicates its carving for food. After this, the active Leeches are selected & transferred in another tray having clean water.

37. Jaloka Shodhan( Cleansing)

38. Pradhan karma/Main Procedure: The desired site is cleaned with wet gauze. Now, the Leech is held at its neck with fingers & applied directly to the skin, 5- 10 Leeches are applied at a time depending upon the necessity. Once Leeches start sucking the blood, they are covered with wet gauze & cold water is poured on them from above time to time, so as to make Leech comfortable during sucking. If Leech do not catch the site by its own, in such condition a small niche or prick induced bleeding may be required so as to facilitate the sucking procedure. The Leech when once starts sucking the blood, elevates its neck, and fixes its head to the supporting point of skin. One can observe wave like movements indicating sucking of blood.

39. When Leech becomes fully satisfied with its food, it leaves off the skin of he patient & drops itself down. If not- then the patient may feel itching sensation which indicates impure blood from that spot is no more available for the Leech. In such a case, a little turmeric powder is placed on the sucking point of the Leech & immediately the Leech takes s away its mouth from that point. Precaution: One should not apply Leeches to major veins like Femoral or Jugular veins and to the delicate parts like Breast, Penis or Eye lids. Used Leeches should be kept in separate jars. Amount of blood loss: Each Leech sucks around 6 to 10 ml of impure blood at one application.

40. Demo 1

41. Demo 2

42. Demo 3(Sucking of blood)

43. Pashchat karma: Post procedure Pateint’s care- Leech is removed from the site The site is cleaned with savlon or normal saline Turmeric powder is placed to the bleeding site Bandaging is done to arrest the bleeding. (sometimes the oozing from the site do not stop, in such cases wound can be sealed with the help of tincture benzene ) Sips of Lime water, Soup or Glucose water can be offered to the patient. Patient is allowed to sit for some time before leaving the place.

44. Dressing

45. Post procedure Jaloka care- Leech after the use is kept in an empty tray. Turmeric powder is placed on its mouth so as to induce vomiting. Immediately after this one may find jets of black coloured blood being emitted by the Leeches. Some of the practitioners advocate to gently squeeze out the blood with fingers from anus to mouth. After this the Leech is again washed in clean water. In the end Leech is transferred in the jar starving for seven days.

46. Jaloka Shodhan

47. Specialty of Leech- A Leech has got an anti- coagulant chemical called Hirudin. While sucking the blood this Hirudin prevent clotting of blood. Ayurveda believes that Leeches suck only the impure part of blood. We can assume the sucking of blood from superficial veins which is deoxygenated or impure one. …...cont. Components of medicinal leech saliva that exert effects in the host's body are:

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