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Background: Raktamokshana, or therapeutic bloodletting, is described in classical Ayurveda as a purificatory procedure, with Jalaukavacharana (leech therapy) being among its principal methods. Objective: To review the classical concepts of Raktamokshana and appraise the contemporary evidence, mainly on leech therapy. Methods: Narrative review based on a PubMed search and classical texts. Findings: In a randomized controlled trial of 51 patients with knee osteoarthritis, a single leech application reduced pain at day 7 more than four weeks of topical diclofenac, with benefits for function and stiffness persisting to the end of the study. Reviews describe more than twenty bioactive substances in leech saliva with analgesic, anti-inflammatory and anticoagulant functions. Case reports describe Jalaukavacharana as part of multimodal management of scalp psoriasis, diabetic foot ulcer and a chronic viper bite ulcer. Conclusion: Leech therapy has some supporting randomized evidence in knee osteoarthritis and a plausible biological basis. Evidence for other forms of Raktamokshana and for other indications is sparse, and safety reporting is limited.