Leech application : a global purview

Dr. Abhiram Thakur, MS (Ay) Scholar

Dr. S. G. Chandini, M.D. (Ay)

Dr. K.B. Sudhikumar, M.D. (Ay)

Leech application is an age old therapy of thousand years around the various corners of  the globe.  Ayurveda as the oldest existing system of medicine thought to be the first to  have the description of this. Apart from us Greek and Romans had also this practice from about two thousand years.                                           

       Around six hundred and fifty species of leech are known till date. Among them about fifteen are in use.  Hirudo medicinalis is mostly used all over as medicinal leech. A Leech can suck  about ten times its own weight without giving any pain sensation. Hence it found to be an useful therapeutic aid in blood letting  all over. In last few decades it had got a good recognition through out the world in the name of Hirudo therapy or leech therapy . Few years before US Food and drug Administration given green signal for the use of leech in America. 

History

As told previously Ayurveda is thought to be the first system t to use leeches. Some historicians differ some times in this regard.  The first Western citation is credited to the Greek, Nicander of Colophon (c 130 BC). In the middle of  19^th century it regained  acceptance . for this many authors refer various events -

In 1985, a Harvard physician was having great difficulty in reattaching the ear of a five-year-old child; the tiny veins kept clotting. He decided to use leeches and the ear was saved. Some author refers that  Contemporary leech therapy was pioneered by the surgeons, M. Derganc and F. Zdravic, who published a paper in 1960 describing the use of leeches to assist in tissue flap surgery. Some other says that a  more contemporary use of leeches was dicovered in 1957 by Markwardt.

Today leeches are bred in farms  in many institutions including Bristol Zoo Gardens and grown a business field too . A huge numbers of leeches are imported from England, Scotland  France, Hungary, the Ukraine, Turkey, Rumania, Russia, Egypt and Algeria.  Leeches have gained new fame in microsurgery, where doctors require the precision of the leech to drain congested blood from wound sites. Plastic surgeons are particularly grateful for the contribution made by the leech, due to their use in the treatment of difficult grafts and reconstructive surgery.

Present  Scenario of  Leech  application

Leech application is in practice in india traditionally from thousands of years. About no modification we have obtained in our procedure. How ever world scenario is some what different. Years before leech therapy was thought to be an orthodox way of treatment. As we saw only in the middle of twentieth century it was reestablished . Now many researches have been conducted all over the world on the effect of leech application in  various pathological conditions. Leech application to reduce venous congestion in reconstructive surgery, osteoarthritis are the leading field where it has been proved clinically too.  It is reported that Nadine Connor , scientist from University of Wisconsin at Madison have developed a mechanical leech. The device, which looks a little like a small bottle attached to a suction cup, delivers an anti-clotting drug to damaged tissue and then gently sucks out as much blood as needed. Many advantage and disadvantage are associated with it.

Major contemporary  application

 Reconstructive surgery

Leeches are now in use to  save lives and limbs, by reducing severe and dangerous venous engorgement post-surgery in fingers, toes, ear, and scalp reattachments., limb transplants, skin flap surgery; and breast reconstruction.

The surgeon usually has little difficult connecting the two ends of small arteries, since arteries are thick-walled and relatively simple to suture  However, veins are thin-walled, fragile, and difficult to suture. The surgeon may thus get blood flowing in the reattached arteries but not in the veins. With the venous circulation severely compromised, the blood going to the reattached body part becomes congested and stagnant. The reattached part turns blue and lifeless and is at risk of being lost. In this stage  of threatening venous insufficiency, but in presence of  adequate arterial flow leech application are proving to be an emerging successful therapy.

In this contest we may remember the jalouka indication as ‘grathite jalajanmabhih’ in our texts. But, now many cases are reported to be prone to be infected by Aeromonas hydrophila and some viruses occasionally.. Hence a preventive measure is essential for this , especially in sophisticated surgeries.

Osteoarthritis

Acharya Vagbhatta has indicated raktamokshana in Gridhrasi at the region of knee joint and in case of krostukashirsaka at gulpha . but generally raktamokshana is contraindicated in vatavyadhi. So, generally Indian Ayurveda physcician are not practicing jalouka karma in OA.

A group of doctors from essen, germany have published a research report  as  significant success in the management of pain, stiffness and function of the joints after leech application, with comparison to topical diclofenac application. Many researchers and physician from different part of the globe are also having reports in its favor. However the property of leech saliva is not yet clearly explained regarding its pharmacology of action.

Many researches indicate that the leech saliva possesses the effect of normalization and improvement of capillary circulation,  anti-inflammatory effect, antistressful and adaptogene effects, immunostimulating and  immunomodulating effects, anesthesia, anticoagulation, antibacterial effect, improvement of an endocellular exhange .

Haematoma

Boxers in the United States traditionally  use leech in the swollen haematomas formed  after boxing  so-called "blue eye" . By the employment  swelling  mostly disappear  with in few days of  leech therapy . Even our texts advise blood letting by jalouka in sopha yukta vrana. In clinical practice also we are getting good result in the same.

Eye diseases

 It is observed in different trials that the acute accumulation with Glaucoma responds well to a leech therapy. The headache and the eye pain mostly omit after setting the leech relatively rapidly and the internal pressure of the eyes regains its normacy. Apart from glaucoma leech application are practiced in many other diseases inside  India as well as abroad .Acharya Sushruta has indicated it   ….                        Some western authors advise the therapy in some inflammatory eye diseases like -  Chorioiditis, Chorioretinitis, Iridochorioiditis, Keratoiritis, Retrobulbaerneuritis, Skleritis etc.

Varicose vein

Many researchers from different corners of the globe had obtained impressive result in management of complications of varicose vein. Study by a panel of doctors in King Edward VII memorial hospital, Mumbai reported to obtain good relieve from oedema, hyper pigmentation like complications by leech application.

 Pain relieve and other uses

Egypt has a long tradition of leech application. With addition to blood vitiated disorder physcician of this region use leech in management of pain like headache, pain due to muscular cramp etc. Some texts advise it in complaints like  - Rheumatism, Arthrosis, Volume disk problems, Pulling, Bruises, Muscular pains, Muscle injuries.

Leech application is also widely practiced in other diseses related to circulatory insufficiency like – Thrombose , Cramp veins, Hemorrhoid, Cardiac infarct, Impact accumulations, Calcifying the containers, Tinnitus.

Ayurveda and modern approach of action of Leech application.

Acharya Sushruta describes that as leeches lives in water, it is  having cold character and is madhura in rasa. Hence iffective in the management of Pitta dusti.  During the process of feeding, leeches secrete a complex mixture of different biologically and pharmacologically active substances into the wound. Hirudin is the best known component of leech saliva. Hirudin is the most important active ingredient  in leech saliva. Many other active substances  and thir actions are:

Hirudin	Inhibits blood coagulation by binding to thrombin
Calin	Inhibits blood coagulation by blocking the binding of von Willebrand factor to collagen. Inhibits collagen- mediated platelet aggregation
Destabilase	Monomerizing activity. Dissolves fibrin. Thrombolytic effects
Hirustasin	Inhibits kallikrein, trypsin, chymotrypsin, neutropholic cathepsin G
Bdellins	Anti-inflammatory. Inhibits trypsin, plasmin, acrosin
Hyaluronidase	Increases interstitial viscosity. Antibiotic
Tryptase inhibitor	Inhibits proteolytic enzymes of host mast cells
Eglins	Anti-inflammatory. Inhibit the activity of alpha-chymotrypsin, chymase, substilisin, elastase, cathepsin G
Factor Xa inhibitor	Inhibits the activity of coagulation factor xa by forming equimolar complexes
Complement inhibitors	May possibly replace natural complement inhibitors if they are deficient
Carboxypeptidase A inhibitors	Increases the inflow of blood at the bite site
Histaminelike substances	Vasodilator. Increases the inflow of blood at the bite site
Acetylcholine	Vasodilator
Anesthetics subsctance	Anesthetic

Some Excellency in leech therapy :-

• Leech therapy in gross penoscrotal oedema in terminally ill patients with advanced prostate carcinoma:-Penoscrotal oedema in patients with hormone-refractory prostate cancer is an uncommon but very distressing complication. Management in these terminally ill patients should provide swift symptomatic relief.  The use of leech in these cases has been reported to have a better effect.  The use of leeches has also been reported in the successful treatment of postoperative penile swelling as well as scrotal haematoma.
• Meningococcal purpura fulminans treated with medicinal leeches :- According to a report by Department of Paediatrics and Child Health, University of Stellenbosch, Tygerberg Children's Hospital, Tygerberg, South Africa : A 5-wk-old female infant with meningococcal meningitis and septicemia and progressive purpura fulminans of the left hand was treated with medicinal leeches. Medicinal leeches were applied to the left dorsal hand on a daily basis for 4 consecutive days. In result it was noted that the swelling and limited functionality visibly improved after 48 hrs, and by 120 hrs, perfusion in the distal phalanges of the thumb and middle finger was evident. Reperfusion of the distal phalanges was not fully sustained, and at 6 wks the plastic surgery department debrided the distal phalanges of her left hand, excluding the thumb. She fully recovered from the meningococcal septicemic shock; the functionality of her left thumb was preserved, and she has limited functionality of her left hand.
• Leech application in Systemic Lupus Erythematus:- A RCT conducted by Nephrology Department, People's Hospital of Guizhou Province, Guiyang, China has obtained a significant reduction in the levels of plasma endothelin and soluble interleukin-2 receptor in patients with systemic lupus erythematosus.

In this way some excellent case reprt as well as researches have proved the efficacy of Leech application in the globe.

Discussion

So, these are the saga of leech therapy , those being used in various diseases according to the consideration of physicians. Mostly to improve blood supply to a region, getting out the pooled blood  and inducing haemolysis for a topical lesion it has got tremendous success. However the infection by Aeromonas hydrophila in cases of plastic surgery cases have opened a new  window to think about the prophylaxis measure in future. In this regard detail description of leech application, detoxification of the animal before use with Turmeric water exhibits the Excellancy of Indians. “Pragyanam brahma” being narrated  by our ancestors it will be a step     forward for “ Krunwanthu Viswam Aryam” if some more research and expansion of this sutrakrit knowledge will also be completed in India again.