Chapter 27: Siravyadha Vidhi

Venesetion (Blood Letting) Let us learn about ancient blood letting therapy of Ayurveda, its indications, procedure, side effects and so on. This is the 27th chapter of Ashtanga Hrudaya Sutrasthana, written by Acharya Vagbhata, son of Vaidyapathi Simhagupta. The chapter name is Siravadha Vidhi Adhyaya. Sira means vein. Vyadha means puncturing.

Shuddharakta Laksana- Features of pure blood:मधुरं लवणं कि जत ् अशीतो णमसंह तम ् प े

गोपहे म ा वशशलो हतलो हतम ् १

लो हतं

भवः शु ं तनो तेनैव च ि थ तः

Slightly sweet and salt in taste neither cold nor hot, resembling the colour of lotus, Indragopa insect, gold, blood of sheep and rabbit - are the characteristic properties of pure blood; It is the cause of origin of the body, by it, is determined the condition of body as healthy or unhealthy. 1-1 ½

Effect of vitiated blood – Dushtaraka Karmaति प त ले मलैः

ाये द ू यते कु ते ततः

वसप व ध ल हगु माि नसदन वरान ्

मख ु ने शरोरोगमदत ृ लवणा यताः

कु ठवाता

प ता क व लो गर मान ्

शीतो णि न ध

ा यै प ा ता च ये गदाः

स य सा या न स

यि त ते च र तकोपजाः

Blood usually gets vitiated by Pitta and Kapha. It produces diseases such as Visarpa- Herpes, Vidradhi – Abscesses, Pleeha – Disease of the spleen, Splenomegaly Gulma – Tumors of the abdomen Agnisadana – Dyspepsia, Jvara – fever Mukha, Netra Shiroroga – diseases of the mouth, eyes and the head; Mada – intoxication- toxicity, Trut – excessive thirst

Lavanasyata – salty taste in the mouth, Vatasra- Gout, Pittasra- bleeding disease, belching with pungent and sour tastes and dizziness. Those curable diseases, not getting cured even after appropriate cold or hot, unctuous or dry treatment should be understood as being born from aggravated blood. 1 ½- 4 ½ तेषु

ाव यतुं र तमु

तं यधयेि सराम ्

In order to drain out the vitiated blood in these diseases veins should be cut. 5

Persons unsuitable for venesection – Siravyadha Anarha – न तूनषोडशातीतस त य द ुतास ृजाम ्

अि न धा वे दता यथ वे दता नलरो गणाम ् ग भणीसू तकाजीण प ता

वासका सनाम ्

अतीसारोदर छ पा डुसवा गशो फनाम ् नेहपीते

नायि

यु तेषु तथा प चसु कमसु

तां सरां व ये न तय गा यनुि थताम ्

ना तशीतो णवाता े वे य ा य यका गदात ्

Who are less than sixteen and more than 70 years of age, who have had no bleeding previously – any time due to any cause, who have undergone excess gone Snehakarma and sweating therapies, those suffering from diseases of Vata origin, the pregnant woman, the woman in parturition, those suffering from indigestion, bleeding diseases, Shwasa (dyspnoea), Kasa – cough, cold Atisara – diarrhoea, dysentery Udara – ascites, intestinal obstruction / enlargement of the abdomen, Chardi – Vomiting Pandu – anemia Chardi – Vomiting, dropsy; for those who have been given fat – ghee or oil to drink – as part of oleation therapy, and who are undergoing the Panchakarma treatment. The vein should not be cut without enforcing control on the body – as described further, that vein which is horizontal, that which has not been raised up; not on day which are very cold, very hot, very windy, or cloudy datys, venesection should not be done. 6-8 ½

Selection of site of venesection- Vyadhana sthana nirdeshaशरोने वकारे षु लला यां मो येि सराम ् ९

अपा

यामप ु ना यां वा कणरोगेषु कणजाम ्

नासारोगेषु नासा े ि थताम ् नासाललाटयोः १०

पीनसे मख ु रोगेषु िज वौ ठहनत ु ालग ु ाः ज ू व ि थषु

ीवाकणश ख शरः

ताः ११

उरोपा गाललाट था उ मादे अप म ृतौ पुनः हनुस धौ सम ते वा सरां

ूम यगा मनीम ् १२

व धौ पा वशूलेच पा वक ा तना तरे

तत ृ ीयके असंय ोम ये

क ध य अध चतथ ु के १३

वा हकायां शू ल यां

ो णतो

वय गुले ि थताम ्

शु मे ामये मे े उ गां गलग डयोः १४ गृ

इ

यां जानुनो अध ताद ू व वा चतुर गुले

ब तेरधो अप यां

ऊ व गु फ य स

वय गुले चतुर गुले १५

यत , तथा

ो टु कशीषके

पाददाहे खुडे हष वपा यां वातक टके च पे च

गृ

वय गल ु े व येदप ु र

ममणः

या मव व वा याम ् यथो तानामदशने

ममह ने यथास ने दे शे अ यां यधयेत ् सराम ् In diseases of the head and eyes veins situated on the forehead, outer angle of the eyes or the area around the nose should be cut; In diseases of the ear, the veins near the ear; in diseases of the nose, vein located at the tip of the nose; in Rhinitis, vein located in the nose and forehead, in Jaw or palate; in tumors of parts above the shoulders, vein situated in the tongue, lips, lower Jaw or palate; in tumors parts above the shoulders, veins at neck, ears, temples, or the head, in Jaw; in all diseases of the head usually vein situated in between the eyebrows; In Vidradhi (abscesses) and pain in the flanks, vein situated between the flanks, Axilla and breast; in fever of every third day (Truteeyaka), vein in the centre of the shoulders; in fever of every fourth day (chaturthaka) – that below the shoulder; in dysentery accompanied with pain vein situated two Angula away from the pelvis, in diseases of the semen and penis, vein situated in the penis; in glandular enlargement of the neck (Apachi), that situated in the thigh; in Gridhrasi- sciatica vein situated at four Angula below or above the knee joints; in Apachi (goiter) vein situated about two Angula below the indrabasti- a vital spot in the centre of calf muscle; in pain of thighs and Krostukasira (inflammatory swelling of the knee joint), Daha of the soleas, Khuda (gout) Padaharsa- (tingling sensation in feet), Vipadika – fissures of the feet, Vatakantaka (sprain of the foot/ Ankle) and Chippa (A diseases of the nails of the toes), vein situated two

Angula above the Kshipramarma- vital Spot in between the big toe and the next toe; in Vishvachi- pain in the arms in the same way as that of Gridhrasi- sciatica should be cut. If the veins are hot visible, another vein situated at nearby place, which is devoid of vital spots should be cut. 9-17

Siravyadha vidhi- Venesection/blood letting rituals and procedure अथ ि न धतनु स जसव पकरणो बल

कृत व

ययनः ि न धरसा न भोिजतः

अि नतापातपि व नो जानू चासनसंि थतः म ृद ुप ा तकेशा तो जानु था पतकूपरः म ृि ट यां व

गभा यां म ये गाढं नपीडये त ्

द त पीडनो कास ग डा माना न चाचरे त ् प ृ ठतो य

ये चैनं व

क धरायां प र

य

मावे टय नरः य या तवामतजनीम ्

एषो अ तमुखव यानां सराणां य

णे व धः

The patient who should undergo Snehana procedure. All the necessary equipments should be kept ready. The person should be strong, should perform Auspicious rites and consume meat-juice and boiled rice mixed with ghee, The person should be exposed to sunlight or fire for sweating. He is asked to sit on a stool of the height of the knee. A band of soft cloth should be tied around his head at the lower border of the hairs; He should keep elbows on his knees, His neck massaged briskly with fists in which pad of cloth is healed; Grinding the teeth, coughing, inflating the mouth to enlarge the cheeks, should also be done his body Trunk should be wound with a band of cloth, controlled – by knots at the back; His neck should also be tied with a band of cloth and tightened This is the mode of raising the deep seated veins.18-22 ततो म यमया अ गु या वै यो अ गु ठ वमु तया

ताडये त ् उि थतां

ा वा

पशा वा अ गु ठपीडनैः

कुठाया ल ये म ये वामह तग ृह तया

फलो ेशे सु न क पं सरां, त व च मो येत ् ताडयन ् पी यं चै नां

Then the physician should tap the raised vein with his middle finger tripped off by the thumb; noticing the elevation, or raising it, once again by kneading it with the thumb; then holding the axe with his left hand, place its edge on the middle portion of the vein and give up in the Axe without Shaking.

Axe should be lifted up in the same way, tapping and kneading the vein for making more blood to come out. 23-24 व ये

ी हमुखेन तु

अ गु ठे नो नम या े ना सकामुपना सकाम ् The vein- of the nose should be cut with the Vrihimukha Sastra- the Lancet with its face shaped like a grain of rice after raising the tip and the surrounding areas of the near with the thumb. 25 अ यु नत वद टा िज व याध तदा याम ् The vein situated underneath the tongue, be cut by asking the patient to keep the tip of the tongue raised and biting it holding it firmly by the upper row of teeth. 25 ½ य

ये

तनयो

व

ीव

पाषानगभह त य जानु थे

ते सरा यधे स ृते भुजेकु े रार य म ृ दते व ये ब ो वप के

For cutting the veins of the neck, they should be raised by manipulating the area above the breasts, the patient is made to hold a stone in each of his fists and keep the shoulders on his knees and outstretched; the body is massaged commencing with the pit of the stomach in the upward direction and then the vein is cut. 25 ½- 27 वधये ब

त सरां बाहावनाकुि चतकूपरे

वा सुखोप व ट य मिु टम गु ठग भणम ्

ऊ व वे य दे शाच प कां चतुर गुले

The veins of the hand be cut, when the patient is sitting comfortably, keeping his arm straight without bending at all elbow, clenching the first with the fingers folded inside, a band of cloth tied, four Angula above the site of cutting. 28-28 ½ व येदालल बमान य बाहु यां पा वयोः सराम ् टे मेहने ज घा सरां जानु यकुि चते

The veins of the flanks be cut, by keeping the arms hanging loose; Those of the pains when it is flaccid; those of the calves when the leg, four Angula above the site of cutting. 29-29 ½ पादे त ु सुि थते अध ता जानुस धे नपी डते गाढं करा यामागु फं चरणे त य चोप र ब

वतीये कुि चते कि चता ढे

तव ततः

वा व येि सराम ्

Those of the feet be cut, when the feet are kept steady, the foreleg is massaged briskly from the knee downwards towards the Ankle with the hands, tying a band similar to the method described for hand, the other leg is kept slightly bent. 30-31 इ थमनु ते व प क पयेत ्

तेषु तेषु

दे शेषु त त य

मुपाय वत ्

Thus the clever physician should adopt such methods of raising the veins appropriate to the places, by the techniques that are not mentioned here. 32 मांसले न यवाधम

पे ेशे

ी या यं

ी हमा कम ्

नामुप र सरां व यन ् कुठा रकाम ्

On fleshly parts, the Vrihimukha Sastra (Lancet) should be used and the vein cut to the size of a rice grain only; the veins on the bones should be cut the size of half a (Yava) barley by using the axe. 33

Samyak Viddha Lakshana संयि व ां

वे ारां य

े मु ते तु न

वेत ्

When the cutting is proper, the blood flows out in a steady stream and stops when the control (tourniquet) is released.

Asamyak Biddha Lakshana अ पकालं बह य पं द ु व ा तैलचूणनैः When the cutting is inadequate; the flow is only for a short time and less in quantity; Then it should be rubbed with oil mixed with lime powder to promote more bleeding;

Ati Biddha Lakshana सश दम त व ा त ु

वेत ् द ुःखेन धायते

When the cut is more, the blood flows out with a sound and stops with great difficulty. 34

Asruti Karana:- causes for non- flowing:भी मू छाय

शै थ यकु ठश

ा तत ृ तयः

ाम ववे गता वे दा र त य अ ु त हे तवः

Fear, fainting, loose tourniquet, blunt instruments, over- satiation (excess eating), debility, patent urges- of urine, faeces etc, absence of sweating therapy- are the causes of absence of blood flow. 35 अस यग े

व त वे ल योष नशानतैः

सागारधूमलवणतैलै द याि छरामुखम ् स य

व ृ ते को णेन तैलेन लवणेन च

When the blood is not flowing out in sufficient quantity, the cut end of the vein should be smeared with oil processed with Vella (Vidanga), Vyosha (Trikatu), Haridra, Nata, Agaradhuma or Lavana, when the blood is flowing out properly, the site should be smeared with warm oil and salt. 36-37 अ े

व त द ु टा ं कुसु भा दव पी तका

Vitiated blood flows out first, just like the yellow- juice form the second seeds of Kusumbhabefore its oil flows out. स य

वा

वयं त ठे छु ं त द त नाहरे त ्

After sufficient bleeding, the flow stops by itself; it should be considered as pure, unvitiated blood and further flow should not be attended. 38 य

ं वमु य मू छायां वीिजते यजनैः पुनः

ावये मू छ त पन ु

वपरे यु

यहे अ प वा

If during the time of bleeding, the patient faints, then the touriniquet should be released, he should be fanned with fans to make him conscious and bleeding continued. If he faints again, blood letting should be postponed to the next day or third day. 39

Dushtarakta Lakshana- characteristics of impure blood – वातात ् याव णं

ं वे ग ा व अ छफे नलम ्

Blood vitiated by Vata, will be blue or crimson in color, dry- nonslimy, flows with force, clear and frothy; प तात ् पीता सतं व म क धौ या सचि

कम ् ४०

Blood vitiated by pitta will be yellow or black, has foul smell, not thick because of increase of heat and mixed with glistening particles, कफात ् ि न धं अस ृ पा डु त तुमि पि छल घनम ्

Blood vitiated by Kapha will be unctuous, pale -yellowish- white in color, has small threads, is slimy and thick; स प ृ ट ल गं संस गात ्

दोषं म लना वलम ्

By combination of 2 Doshas, there will be mixed features. Blood vitiated by all the Doshas will be dirty and thick. 40-41

Srava pramana- Quantity of flow:अशु ो ब लनो अ य ं न

अ त ुतौ ह म ृ युः

था

ावये परम ्

या ा णा वा चलामयाः

त ा य गस ीरर तपाना न भेषजम ् Vitiated blood more than one Prastha- (768 ml) should not be allowed to flow out, even in strong persons; Excess bleeding will lead to either death or dreadful diseases of vata origin. In such condition, oil massage and drinking of milk mixed with blood are the treatment. 42 त ु े र ते शनैय

मपनीय हमा बन ु ा

ा य तैल लोता तं ब धनीयं सरामुखम ्

After the flow of blood, the controls should be removed slowly, the site washed with cold water, the cut end of the vein covered with a cotton swab soaked in oil and bandaged. 43 अशु ं

ावये त ु ः सायमह यपरे अ प वा

नेहोप कृतदे ह य प ा वा भ ृशद ू षतम ्

Vitiated blood should be removed again either in the same evening or next day; if the blood is found greatly vitiated with more quantity of Doshas. It should be removed again after a fortnight, after administering Snehana therapy. 44 कि च

शेषे द ु टा े नैव रोगो अ तवतते

सशेषम यतो धाय न चा त ु तमाचरे त ्

If a small residue of vitiated blood inside, diseases do not get aggravated and so it can be allowed to stay, but excess flow of blood should not be attempted. 45 हरे ि

गा द भः शेषं

शीतोपचार प ता द ु टं र तमनु

सादमथवा नयेत ्

याशु

तमेवमे व

वशोषणैः सादयेत ्

Such residual blood may be removed by making use of the sucking horn (Shrunga)etc. or it can be purified of doshas by administering cold comforts, therapies prescribed for Raktapitta (bleeding diseases), purification therapies (Panchakarma) etc. and by methods of making the body thin. Even the blood which is mildly vitiated by the Doshas but not increased in quantity should be treated by these methods. 46-47 र ते व त ठ त

ं

त भनीमाचरोि

याम ् । रो

म ृ कपाला जन ौममषीकषी र वग कुरैः । वचन ू ये

तामेव वा सरां व ये

य गुप त गमाषय

याहवगै रकैः ।।

णमुखं प का द हमं पबेत ् ।।

यधा त मादन तरम ् । सरामुखं वा व रतं दे ह त तशलाकया ।।

If the bleeding does not stop, methods to stop it should be adopted; the orifice of the wound should be smeared with the powder of either Rodhra, Priyangu, Pattanga, Masha (black gram), Yashti (licorice), Gairika, Mritkapala (pot shred), Kshana Masha, ash of flax or of the bark and sprouts of trees with milky Sap by cold infusion prepared from drugs of Padmakadi Gana – vide