Rakta Mokshana with Jaloukas (Blood Letting with Leech Therapy)


Blood letting therapy is considered by some ancient ayurvedists as one among the famed "Panchakarmas" - five purification therapies. While Charaka considered Vamana (emesis), Virechana (purgation), Nasya (instillation of medication into the nose), and 2 types of Bastis (enemata) the five main purification therapies, Sushruta considered Vamana, Virechana, Nasya, Basti (one type), and Rakta Mokshana the five therapies. In addition to the tridoshas of Vata, Pitta, and Kapha, Sushruta considered Rakta to be the fourth dosha. Because Rakta Mokshana corrects the imbalances of Rakta, it is considered to be amongst the Panchakarma.

There are a variety of ways to perform blood letting. They are briefly as follows:

1. Sira vyadha- puncturing a vein by using a sharp instrument to allow the toxic blood to drain

2. Pracchana- Making a superficial scratch on the skin and allowing the blood to ooze slowly.

3. Shringa- Making a wound on the skin and draining the blood by creating a vacum with an animal horn.

4. Alabu- Using a dried vegetable gourd to drain blood with a suction technique

4. Jalouka- Using non-poisonous leeches

Of the variety of techniques mentioned above, jalka is the only one that is commonly practiced in ayurvedic hospitals. The others are almost obsolete now, but may be practiced by some traditional vaidyas and folklore practitioners.

Over the last few years, I've been fortunate to see leech therapy a few times at the hospital attached to my college. My classmate agreed to go through the process for her stubborn acne. She underwent one sitting and discontinued after that. As she only went through the procedure once, she did not benefit much from it. In the past two weeks, I've seen two leech procedures for a patient suffering from pustular acne. A postgrad student at our college is studying the effect of rakta mokshana using leeches in patients with acne. In addition to four sittings of leech therapy, the patients are instructed to take oral medication as well. His initial findings have been encouraging, but the efficacy of the overall treatment can only be evaluated in a few months.

Procedure of Jalouka:

Leeches:
The leeches selected for rakta mokshana should be non poisonous. They should be stored in fresh water, which should be changed every 3-4 days. While the classics state that they should be fed with algae and other natural food, the leeches can survive without food for quite a long time.

Selection of Patients:
While the other panchakarma therapies can be associated with many complications, jalouka therapy very rarely results in complications. In fact classical ayurvedic texts say that this can be administered to children, the elderly, pregnant women, and those of delicate constitutions. Thus there is a wide range of patients who can be chosen for this procedure.

The Site:
The site may be on the actual lesion or in an area nearby. The procedures I saw were administered on the specific lesions.

Method:
1. The area is exposed well and leech is placed on the skin. Sometimes the leech begins to suck itself. If it does not start sucking, a small would should be made in the skin and the leech reintroduced to the area. The classics mention rubbing the area with rough substances or making a linear incision in the area. Nowadays, a sterile needle is used to make a small wound.


2. After the leech attaches itself, a piece of sterile gauze is dipped in water and then placed over the leech.
3. The leech is left undisturbed until it falls off by itself or until the patient feels pain or itching in the area. This indicates that the leech is sucking pure blood (without toxins).
4. The wound is covered with the powder of yastimadhu (Glycyrrhiza glabra) and then covered with a sterile gauze piece.
5. THe leech is then induced to vomit the toxic blood that it has just sucked. If vomiting is not induced, the leech enters a toxic state called "Indra Mada" and then dies. Vomiting is induced by sprinkling the powder of haridra (Curcuma longa) on the leeches mouth. This usually makes the leech vomit on its own. If there is any residual blood in the leech, it can even be manually milked from its tail end to head end.
6. The leech should not be used again for rakta mokshana for at least 7 days, as mentioned by the classics. While some hospitals use the same leeches for different patients, it is advisable to use the leeches for one patient only and then discard them. There has not been any research about the transmission of hematogenous diseases through leeches. Until such research is done, reusing leeches should be highly discouraged.

Indications of Rakta Mokshana
It is considered the main line of treatment in any diseases where rakta dosha/dhatu is affected. This mainly refers to all skin diseases, called Kushta in ayurveda. It can even be used in cases of Arbuda, Granthi, and Gulma, which can be compared to various neoplastic growths.

Rakta Mokshana has been described in detail in many of the ayurvedic classical texts. Unfortunately nowadays it takes a backseat to more traditional ayurvedic therapies. It is encouraging that some centers are doing much needed research in this area.

The third upastambha is brahmacharya, which has a broad range of meanings in Indian culture. Brahmacharya is the first stage of Hindu life, during which a person focuses on education and religious study. In Ashtanga Yoga, brahmacharya is included as one of the moral prerequisites for further yogic study. It is included under the first of eight stages called yama and basically refers to celibacy. In Ayurveda, the word has a broader meaning. It refers to two things-

1) control over the sense organs
2) acquiring knowledge of Brahman (Paramatma- Supreme Being)

Control of the sense organs implies the proper utilization of them. Here, we are not only considering the five special senses (sight, smell, hearing, touch, and taste). We must also consider the 5 karmendriyas, organs of action- hands, feet, and organs of speech, reproduction, and excretion). These 10 indriyas must be utilized for the right purpose and in the correct manner. Excess utilization, under utilization, and perverted utilization of the sense organs leads to physical and mental imbalance. Thus they should be avoided.

For example, let's consider the sense of sight- chakshu indriya. Excess utilzation of this sense organ would be staring at anything for too long, especially bright objects- the sun. Under utilization would be sleeping or meditating for long hours, wherein the eyes are not being used enough. Perverted utilization is anything from watching horror movies, pornography, to anything else that has the potential to disturb the mind. Similarly, one can elaborate examples for the other indriyas.

Control of the senses implies a certain degree of austerity as well. This type of thinking seems completely out of place in the 21st century, as most of us are accustomed to instant gratification. Have you ever wanted a cookie or pastry at a grocery store and eaten it before you got to the check out? That's what I mean by instant gratification. We have grown so used to immediately satisfying our fleeting desires that just as one is satisfied another creeps up. This is where we should use some restraint. I'm not advocating renunciation or strict vows- just a little bit of patience and restraint. Next time you feel an intense desire to do something, see something, eat something, just observe your feelings. If you observe long enough, many times the desire just floats away. This type of restraint will be useful to check the desires that once gratified, make us feel guilty later- having one drink or dessert too many, saying something in a state of anger or sadness, etc.

Acquiring knowledge of Brahman is the other aspect of Brahmacharya. This illustrates that Ayurveda is as much about the spirit and mind as it is about the body. Spiritual growth and understanding are essential for healthy living. While living in this world, we must also be aware of what is beyond this material experience. This is the only knowledge that can free a person from the cycle of birth, disease, old age, and death.

There are many methods to acquire knowledge of Brahman. The most basic are explained under "Sadvritta" in Ayurveda. Sadvritta means good conduct or right living. Chapter 8 of Charaka's Sutrasthana is completely dedicated to explaining sadvritta. Here are a few examples:

1)Pay respect to Gods, elders, teachers, and spiritually advanced people
2)Be envious of the means and not the result (insted of being jealous of someone's riches, be envious of the way in which she acquired the wealth)
3)Speak timely, measured, and sweet words
4)Reconcile the angry, console the frightened, be merciful to the poor
5)Speak the truth
6)Do not commit sin, even against someone who is a sinner
7)Do not criticize others or disclose the secrets of others
8)Do not eat without offering food to Gods, ancestors, poor; without washing hands and face; with a disturbed mind
9)Do not postpone things or indulge in anything without proper examination of the pros and cons
10)Always be well dressed, have a pleasant disposition, and maintain hygiene.

As you can see, Charaka explained conduct that ranges from the mundane- clothing - to the philosophical. Our conduct determines our state of mind and it is only with a balanced, healthy state of mind can we acquire knowledge of Brahman, Jesus, Allah, Buddha, etc. Thus morality is part and parcel of spiritual practice. While prayer, yoga, meditation, fasting, pilgrimage, and religious ceremonies are all very powerful practices, they are essentially useless if the person doing them does not practice sadvritta, or right living.

In conclusion, the three upastambhas or sub pillars of life, aahara, nidra, and brahmacharya, have been explained in brief. Think about how they affect your life and how you can work towards employing them to maintain a healthy body and mind.

Nidra

Nidra is exactly what I should be doing now, but alas, this is the only time I can steal away to update this fledgling blog. Nidra is considered the second "upastambha" or sub-pillar, of life. Like Ayurveda, modern science acknowledges the indispensability of sleep. However, it has not been able to specifically delineate the functions of sleep.

A modern anatomy and physiology text book defines sleep as "a state of altered consciousness or partial consciousness from which an individual can be aroused," (Tortora 2003). It goes on to discuss the two components of sleep, namely non-rapid eye movement sleep (NREM) and rapid eye movement sleep (REM). During NREM sleep, we move from light sleep to fairly deep sleep within the span of one hour. Body temperature and blood pressure decrease slightly. REM sleep is characterized by rapid eye movement and most dreaming occurs during this phase. NREM sleep and REM sleep occur cyclically, with REM sleep occurring every 90 minutes for a varying period of time. As we age, we experience shorter periods of REM sleep. For example, 50% of an infants sleep is REM sleep as opposed to 25% for adults. Brain activity and blood flow are higher during REM sleep, and it has thus been identified as an important factor in the growth and maturation of a child's brain. Adenosine is an important chemical in the physiology of sleep. Adenosine, liberated by ATP during periods of energy utilization, binds to receptors that inhibit the neurons responsible for waking us up. This is why we feel sleepy at the end of intense physical exercise and at the end of a long day. Sufficient amounts of adenosine bind to receptors, which interferes with our ability to stay awake.

Charaka has defined sleep as:

yadaa tu manasi klaante karmaatmaanah klamaanvitaah |
vishayebhyo nivartante tadaa svapati maanavah || ch.su. 21/25

When the mind and sense organs are exhausted, they no longer are able to perceive their objects. At this stage, sleep descends. Thus, wakefulness is dependent on the mind's association with the sense organs and in turn, their association with their objects. When we read a book, the mind interprets what the eyes are reading. When the mind begins to slow or wander, it can no longer analyze what is being read. At this stage, either sleep manifests or we get distracted with a different object that allures the senses.

Charaka has gone a step further than modern physiology textbooks to emphatically state that nidra is essential for the following reasons:

nidraayattam sukham duhkham pushti kaarshyam balaabalam |
vrshataa kliibataa jnaanam ajnaanam jiivitam na cha ||

Happiness, misery, nourishment, emaciation, strength, weakness, virility, sterility, knowledge, ignorance, life and death are all dependent on proper or improper sleep. With this in mind, he explains some rules (yes rules!! Ayurveda has many!) that govern sleep.

Raatri jaagarana (staying awake at night) and divaasvapna (napping during the day) are generally contraindicated. The former causes an increase of Vata dosha, which if prolonged, can result in emaciation, debility, and many Vata dominant disorders, such as psychological/neurological disturbances, as well as musculo-skeletal disorders. You are allowed to burn the midnight oil in one condition- that is as a remedy for napping too much during the day! Divaasvapna causes an increase in Kapha dosha, and as Vata and Kapha are opposites, wakefulness at night will mitigate the effects of napping during the day. The same is true for the opposite- if you stay up too late the night before, you may sleep 1/2 the amount of time you remained awake. However, you should sleep on an empty stomach. Often times we eat a heavy meal in order to induce sleep and sleep the day away. This is just going to aggravate the doshas even more. So best thing is to maintain a regular sleeping cycle, waking and sleeping at similar times everyday. If the regimen is breached, take immediate remedial measures to avoid further imbalance.

Divaasvapna is contraindicated at all times and for everyone. This is so because it leads to an immediate increase in Kapha dosha, as explained above. Increased Kapha manifests as physical and mental sluggishness and will in turn impair the functions of the digestive system and mind. Impairment of the digestive system is one of the causative factors in all disease processes, according to Ayurveda. Thus the "Agni," digestive fire, must be maintained in a healthy state at all cost. The exceptions to this rule include the summer season (especially Indian summers). During the summer, VAta dosha increases. Napping will mediate this relative increase. Similarly, Charaka explains that the elderly, children, and weak may nap, as well as those who indulge in excessive physical exercise/manual labor. Even those who are afflicted with grief, anger, fear, and intoxication have been given the ok. So it's ok to tell your slightly inebriated friend to "Sleep it off!" Thus the much loved siesta after lunch is not a very healthy option according to the classics. If its a 15-30 min. siesta that follows a meal, its ok. But beyond that is really pushing it! If you are accustomed to napping in the afternoon, don't immediately discontinue it. Wean yourself off gradually; otherwise you may experience withdrawal-like symptoms- headaches, irritability, etc.

Lastly, the types of sleep have been explained in Sutrasthana, namely-
1) Tamobhaava nidra: Sleep caused by excess Tamo dosha.
2) Shleshmasamudbhava nidra: Sleep caused by excess Kapha dosha.
3) Mana Shariira sambhava nidra: Sleep caused by excess mental or physical exertion.
4) Aagantuka nidra: Caused by poison, drugs, spirits, etc.
5) Vyadhi anuvartini: Due to a disease.
6) Ratrii svabhaava prabhaava nidra: Physiological sleep caused by the nature of night.

The only normal type of sleep is #6- Ratrii Svabhaava Prabhaava Nidra. The other types of sleep are abnormal and remedial measures should be taken in case they manifest often.

The three pillars of svastha are aahaara, nidra, and brahmacharya (food, sleep, and moral and spiritual living). I bet for many of you, the first two sound fabulous:) But don't be deceived so quickly- this does not mean that we can eat and sleep all we want. Ayurveda considers these three aspects of life so integral to health and longevity that whole chapters in classical texts have been devoted to them. I will deal with each in separate posts. First comes the good stuff-- food...yummmmmm:)

Not only has Ayurveda specified rules for eating, but it has also outlined the concept of a 'balanced diet'. Imagine over two thousand years ago, Charaka concised into verse the ideal balanced diet:

shashtika shaali mudgaam cha saindhava aamalake yavaan |
aantariiksham payah sarpi jaangalam madhu cha abhyaset ||
ch.sa.su. 5/12

Shashtika shaali refers to rice, preferably par-boiled (carbohydrates); mudga is green gram (protein); saindhava is rock salt (minerals); aamalake is gooseberry (considered the queen amongst fruits because of its rejuvenation properties); yava is barley (protein); aantariiksham is rain water (electrolytes); payah is milk (calcium and other good stuff); sarpi is ghee (fat); jaangala is the meat of desert animals (protein) ; and madhu is honey (carbohydrates). How does that compare to the current day food pyramid?

Charaka has also highlighted contraindicated foods, namely dried meat, dry vegetables, pork, beef, buffalo meat, fish, yoghurt, and black gram. All of these foods negatively affect the homeostatis of the body and should be avoided as much as possible. Excessive indulgence in such foods will definitely lead to disease, while avoidance will promote good health.

Charaka and other Ayurvedic teachers have expounded many rules governing proper dietetics. These rules concern the quantity, quality, time and manner in which food is consumed. With regards to quantity (something many of us have difficulty controlling!)-

annena kukshe dvaavamshau paanena eka prapuurayet |
aashraya hi pavanaadiinaam chaturtham avasheshitam ||

Translation: The stomach should be filled with two parts of solid food, one part of liquid food, and the fourth part should be left empty for the circulation of the doshas- vata, pitta, and kapha. While under eating does not affect the body too adversely, overeating causes the immediate aggravation of all the doshas simultaneously, which if repeatedly done, causes many obstinate health problems like obesity, diabetes mellitus, etc. So if you are a poor eater, not to worry all that much- there is still hope, but if you are a consistent over eater, better to cut back little by little. Otherwise life will be a struggle in a few years. Overeating once in awhile (especially at parties, weddings, food fests) is understandable and should not be cause for great alarm. But remedial measures should be taken- simple rule: Skip the next meal so that the previous one can be digested completely. Drink small quantities of hot water and remember to take a short walk (100 steps is recommended by the classics) to aid digestion. And of course, don't overeat again the next day, just because you skipped a meal!!

"Svastha" is the Sanskrit word for health and well-being. Literally translated, it means established in one's self, being in one's natural state, which is a beautiful way of expressing complete well-being. For when we are healthy on all levels- physical, emotional, psychological, and spiritual- we are truly established in ourselves. Think of a time when you were balanced in these aspects and try to recollect how you were feeling. For all of us, the emotions will vary, but often times they will include stability, deep happiness, and confidence. This is being established in one's self.

During day to day life, when we are just going though the motions, the focus is outwards on people, places, tasks, and 101 other things. In these situations, we are motivated and energized by the external world and often times we are hurt and wounded by the external world. This is the state of turbulence - chanchala. In a balanced state, a state of svastha, the energy and motivation that carries us through life comes from within. While we completely participate in the external world, we do not let it carry us away.

Svastha is a basic aim of all individuals. Despite our bad habits and tendencies, it is a fundamental value in life. For some, health strictly means physical health- blood levels, heart rate, muscle tone, percent body fat, etc. For others, it is emotional health- being in healthy relationships that are based on honesty and communication. Everyone's definition varies. Ayurveda, the ancient medical science of India, defines health as:

samadosha sama agni cha sama dhatu malakriya
prasanna atma indriya mana svastha iti abhidhiyate

Health is when the doshas are balanced, digestion is optimal, the tissues and organs are healthy, bodily wastes are regularly excreted and the soul, mind and sense organs are pleased. The definition is all encompassing, mentioning the various factors that can confer or destroy health. This blog is all about svastha- our innate desire for health and happiness. As a student of Ayurveda, my aim is personal health on all levels as well as helping others achieve the same. The posts will be a collective of philosophical and practical tidbits. Hope you enjoy reading and please feel free to respond constructively:) Be well.