International Journal of Health Sciences and Research www.ijhsr.org ISSN: 2249-9571

Review Article

Historical Aspects of Therapy: A Critical Review

Malik Itrat1*, Zarnigar2, N. Haque3

1Lecturer, D/o Tahaffuzi Wa Samaji Tib, Allama Iqbal Unani Medical College, Muzaffarnagar, Uttar Pradesh, India. 2Lecturer, D/o Tahaffuzi Wa Samaji Tib, National Institute of Unani medicine, Bangalore, Karnataka 3Lecturer, D/o Ilmul advia, Eram Unani Medical College, Muzaffarnagar, Uttar Pradesh

*Correspondence Email: [email protected]

Received: 03/05//2013 Revised: 17/06/2013 Accepted: 25/06/2013

ABSTRACT

Bloodletting and the therapeutic use of Hirduo medicinalis dated back to the ancient Egypt and the beginning of the civilization. Their popularity has varied over the years. Leech therapy is one of the most important and widely practiced methods of regimental therapy, used for local evacuation of morbid humour in Unani system of Medicine. With the advent of modern pathology, physiology and microbiology in the late 19th century with fell out of favour. The leech once used by physicians of emperor and influential academic surgeon enjoyed a renaissance in reconstructive surgery during the last 15 years. The Leech is no longer ubiquitous, but has warmed its way back into the medical field. This paper presents a brief review on the history of treatment with leech from its origin to the present day.

Key words: Leech, Bloodletting, Regimental therapy, Unani Medicine.

INTRODUCTION of leech therapy is that it may be advised on According to Unani system of those areas of the body where other Medicine, Bloodletting is based on concept processes of -letting like venesection of humoral imbalance. Their imbalance and cupping are not possible. causes diseases, where restoration of the balance leads to health. [1] According to DESCRIPTION OF LEECHES USM majority of diseases are caused by The leech is an aquatic worm with a endogenous factors by excessive flattened body, tapering end terminating in accumulation of blood, foodstuff and morbid circular flattened disc, the hinder one being humours. [2] Bloodletting in the form of larger of two. It swims with a vertical venesection; leech therapy and cupping with undulating motion and moves, when out of scarification is an essential part of water by means of these discs or suckers, regimental therapy. [3] It has been utilized flattening itself first by one and then by for preventive as well as therapeutic other and alternately stretching out and measures for thousands of years by ancient contracting its body. The mouth is placed in Unani physicians. The important advantage the centre of the anterior disc and furnished International Journal of Health Sciences & Research (www.ijhsr.org) 78 Vol.3; Issue: 7; July 2013 with 3 cartilaginous lens shaped jaws. These Hirudotherapy has been mentioned in jaws are lined at their edges with fine sharp Ayurveda by the name of “Jalaukavacharan” teeth and meet so as to make a triangular („Jalauka‟ meaning leeches and „Avacharan‟ incision in the flesh. The head is furnished meaning application). As per Ayurveda with small raised points, supposed by some Jalaukavacharan is one of the procedures of to be eyes. [4] The leech belongs to the Raktamokshana. Raktamokshana is one of kingdom (Animalia); Phylum (Annelida); the biopurification methods mentioned in Class (Hirudinea); Order (Gnathobdellida); Ayurveda, in which humours vitiated in Family (Hirudidae). [5] Leech can ingest an blood are expelled from the body. Ayurveda amount of blood close to that of eight times mentioned various kind of leeches out of of their own weight. The leeches can be which 6 varieties of non-poisonous leeches primarily found in the freshwater lakes, are used for Hirudotherapy. [13] in ponds or rivers ranging from 5cm to nearly emphasize on the use 25 cm. [6] Leeches are hermaphrodite having of leeches even for skin diseases. Later in both male and female parts, but they still the 12th century Abdul Latif Baghdadi wrote need to come together to meet with each that leech could also be used for cleaning the other. After mating 15-50 eggs are laid in tissues after surgical operations. [14] one spongy case or coccon above the Leeching reached the height of its popularity waterline often under stones. The eggs hatch in the middle 19th century, when it was in 3 to 5 weeks and the young leeches need exposed by the French physicians Francois two seasons of feeding before they are ready Broussais (1722-1838). Broussis was the to breed themselves. [7] In India there are head of French physician of the Val De about 45 of leeches belonging to 22 Grace Hospital in Paris and a surgeon in genera. However the species commonly Napoleon‟s grant army. Broussais treated cultured for medicinal use are Hirudinaria diseases such as typhoid fever, Syphilis, granulosa and medicinalis. H. T.B, and even mental illness by applying granulosa is abundantly found in the state of leeches to abdomen. Broussais was in fact Madras, Kerala, M.P, U.P. and Punjab, the biggest consumer in France, ordering 2-3 whereas Hirudo medicinalis is commonly millions leeches in 1824 and his requisition used in western worl. [8] Leeches are known rose to 42 millions in 1833. A record of 57 by following vernacular names: Alaq ( millions leeches was used in 1854. Between Arabic); Zalu ( Persian ); Jonk ( Urdu ); the years of 1829 and 1836, five to six Salook ( Turkish); Leech ( English ); Hirudo millions leeches were used annually in the (Latin); Bdella (Greek); Jaluka (Sanskrit); hospitals of Paris. [15] In early 19th century Jalu ( Hindi); Jalagalu ( Telugu); Attai ( American physician from Georgia wrote Tamil); Jiganey ( Kannada). [9-11] bloodletting is the most important treatment, whenever there appears mark of local HISTORICAL BACKGROUND congestion, inflammation or that sluggish or No one knows exactly when leeches torpid action which makes incapacity in the began to occupy an important role in circulation vessels. He continue to discuss medicine. Varying sources date the leech to the use of leeches as treatment for 2500 years ago, when it was used for myocarditis, peritonitis, pleuritis, hepatitis, bloodletting in ancient Egypt. [12] Leeching gastritis, tonsillitis, nephritis, pneumonia, is also mentioned in medical encyclopedia whopping cough, dysentery, hemorrhoids, from India written in Sanskrit completed acne and pimples. [16] The use of leeches was between 500 BC and 200 AD. discontinued when this practice was International Journal of Health Sciences & Research (www.ijhsr.org) 79 Vol.3; Issue: 7; July 2013 rumored to transmit some diseases. Several cleansed of, with a sponge. The place where infectious diseases were thought to be the leeches are to be applied must be transferred from person to person through (shaved if necessary) well laved with nitre- their applications- syphilis, puerperal fever water and rubbed till red. Dry carefully. Dip and erysipelas being a few. With the advent the leeches in fresh tepid water, cleanse and of modern pathology physiology and apply (with one‟s freshly washed hands, or microbiology in the late 19th century, with soft towel, or in a test tube called a bloodletting with leeches fell out of favour. “leech glass” especially if the place in [17] The leeches was brought back into the question is the palate or gums). The point of medical domain in the middle of the 20th application may be smeared with clay (or century, its use was called as hirudotherapy. moistened with sugar water or milk) or With the advent of microsurgery including scratched with a needle till blood appears, in plastic and reconstructive surgeries the order to coax them to take hold. The leech doctors found a use for the leech in modern must not be let go until it has taken proper medicine, primarily in the reattachment of hold. The leeches when starts sucking the fingers, toes, arms, ears and noses and even blood, it elevates its neck and fixes its head in breast reconstructions. [18] In operation to the supporting point of skin. One can one of the biggest problems that arise is observe wave like movements indicate venous congestion, the excess blood from sucking of blood. When leeches become the injured or reattached tissue needs to be fully satisfied with its food it leaves off the removed. If the blood is not cleared quickly, skin of the patient & drops itself down. If the blood begins to clot, the arteries that not then in such a case, a little turmeric bring the fresh oxygenated blood will powder is placed on the sucking point of the become clogged and the tissues that were leech and immediately the leech takes away reattached will decay and die. Venous its mouth from that point. Leech after the congestion may lead to edema, capillary and use is kept in an empty tray. Turmeric arterial slowing, arterial thrombosis, flap powder is placed on its mouth to induce ischemia and eventual necrosis. The main vomiting. Some of the practitioners advocate reason why leeches are employed in to gently squeezing out the blood with microsurgeries is to reduce this venous fingers. After this leech again washed in congestion. After the operation, the use of clean water. [21, 22] leeches should be withheld as long as possible. This is due to the anesthetic in CHEMICAL COMPOSITION OF LEECH patient‟s body. A leech in contact with SALIVA [23- 25] anesthetic will not feed a phenomenon that The near or total painlessness of is called as lazy leech syndrome. [19] In leech‟s bite is due to the contents of leech 1983, Handerson et al. reported a case where saliva, which contains a number of different leeches were used in the post operative chemical compounds .The saliva of leech treatment of a scalp avulsion case. [20] contains anesthetic, which makes the bite of the leech painless to its host; an histamine LEECHING TECHNIQUE like vasodilator which increases the blood Leeches should be kept a day before flow to the feeding areas by increasing the applying them and they should be squeezed diameter of the blood vessels; and a (or have their heads bent down) to make chemical enzyme called hyaluronidase, them eject the contents of their stomach. The which facilitates the degradation of the slime and debris from their bodies should be connective tissues around the bite site International Journal of Health Sciences & Research (www.ijhsr.org) 80 Vol.3; Issue: 7; July 2013

allowing the vasodilator substance, wider operations and has been recommended for access to the area. There is also an the prevention of phlebitis and post , which is responsible operative pulmonary inflammation. Leech for inhibiting blood coagulation and is saliva also contains several other bioactive employed as an anticoagulant in surgical substances are as mentioned in Table.

Hirudin Inhibits blood coagulation by binding to thrombin. Calin Inhibits blood coagulation by blocking the binding of von willebrand factor to collagen- mediated aggregation. Destabilase Monomerizing activity. Dissolves fibrin. Thrombolytic effects. Hirustasin Inhibits kallikerin, trypsin, chymotrypsin, neutrophilic cathepsin G. Bdellins Anti- inflammatory, Inhibits trypsin, plasmin, and acrosin. Tryptase inhibitor Inhibits proteolytic enzymes of host mast cells. Eglins Anti- inflammatory. Inhibits activity of alpha- chymotrypsin. Complement inhibitors May possibly replace natural complement inhibitors, if they are deficient.

Indications And Contraindications. [26-30] burning and blister formation and ulcerative Indications Contraindications Varicose vein Anemia necrosis due to toxins present in leech saliva Ringworm Diabetes mellitus have also been reported after leech therapy. Alopecia Hemophilia Lymphadenitis Pregnancy Transmission of certain infections from one Malignant ulcer Hypotonia subject to the other is another probable Psoriasis Leukemia complication of leech therapy. [30, 31] Eczema Active tuberculosis Elephantiasis General fatigue Gangrenous wound High temperature SCIENTIFIC REPORTS Osteoarthritis Bleeding disorders Phlebitis and thrombotic Severely ill patients In recent past years, various clinical conditions as well as experimental studies have been Preventing post surgical Bed ridden patients blood clotting conducted globally to evaluate the efficacy Odontalgia, periodonitis and Old aged persons of leech therapy in various ailments using alveolar abscess Post operative skin Around liver, spleen, standardized outcome measures. In a study, grafting lesions stomach & intestine. the hirudin was tested for thrombin Revascularization of amputated On Buttock fingers & toes after repalnatation inhibition in synovial inflammation in procedure Antigen Induced Arthritis (AIA). The study was conducted on models where ADVERSE EFFECTS experiments showed hirudin did indeed The most worrisome complication significantly attenuate the severity of AIA as other than superficial scaring is measured by both 99m TC uptake and hydrophila. This bacterium is a normal synovial histology. The intra-articular fibrin inhabitant in the foregut of the leech. The staining was reduced by hirudin treatment. leech does not contain digestive enzymes to There was a clear reduction seen in synovial break down red blood cells from the blood inflammation by hirudin. [32] In India also, so it relies on bacterial enzymes secretions various studies have been conducted to to digest blood. A. hydrophila can infect the prove the safety and efficacy of leech bite or surrounding skin during feeding, therapy in musculoskeletal and such an infection presents itself as a local dermatological disorders on the basis of abscess. The infection is not reactive to scientific parameters. Another study from penicillin but to chloramphenicol and amino Bangalore, India, has proved the safety and glycoside. Other complications are allergic efficacy of leech therapy in the management reactions such as itching followed by of knee osteoarthritis (OA). In this study, 30 International Journal of Health Sciences & Research (www.ijhsr.org) 81 Vol.3; Issue: 7; July 2013 diagnosed patients of knee OA were 6. Verma PS. A manual of practical subjected to leech therapy and the efficacy zoology . New Delhi: S assessment was done weekly with the help Chand & Company Ltd; 2006: 288- of Western Ontario and McMaster 91. University (WOMAC) OA Scale and Visual 7. Cleave HJV. Zoology. Analogue Scale (VAS) Score. After the 2nd Ed. New York: McGraw-Hill; completion of treatment of one month, these 1931: 153-6. scores were reduced significantly (p<0.05), 8. Barnes RD. Invertebrate Zoology. 3rd thereby proving the efficacy of leech therapy ed. Philadelphia; WB Saunders Co; in OA. [33] 1974: 301-15. 9. Anonymous. The wealth of India. CONCLUSION Vol.6: L-M. New Delhi: Council of Nowadays leeches are used Scientific & Industrial Research; successfully for many conditions notably 2003:57-59. varicose vein and osteoarthritis. Modern 10. Antaki D. Tazkeratul ulil Albab. biochemistry has revealed so many bioactive Vol.2. Beirut: Darul Kutub substances in the leech saliva as well as their alilmiyah; 1998: 27-28, 540-541. mode of action. The anticoagulant property 11. http:// www.theholisticcare.com of Hirudin contained in leech saliva may (Cited 20 October 2012). lead to wider therapeutic application in the 12. Hyson M John. Leech therapy- A prevention and treatment of thromboembolic History. Journal of the history of disease like angina pectoris, coronary dentistry 2005; 53(1): 25-27. thrombosis, atherosclerosis and varicose 13. Verma DK, Chaubey PK, Singh AK, vein. At the same time optimal care should Singh OP. A critical review on be taken when applying leeches because Historical Aspect of Jalaukavacharan their use can be associated with serious (Hirudotherapy). IJRAP [Internet] complications. 2012 Jan-Feb [cited 2012 Dec.25]; 3(1): [about 3p.]. Available from: REFERENCES http://www.google.com/IRJAP/2012/ 1. Kabeeruddin M. Kulliyate Qanoon. Jan/ article on hirudotherapy. Lahore: Sheikh Mohd. Basheer & 14. Hakeem M. Bustanul Mufridat. New Sons; 1930: 350-52. Delhi: Idarae Kitabul shifa; 2000: 2. Tibri Rabban. Firdaus al Hikmat. 138. (Urdu translation by Mohd. Ahmad 15. Wells, Mark D, Manktelow RT, Shah Sambhali) Deoband: Faisal Brian J. The Medical Leech- An old publications; 2002: 306. treatment revisited. Microsurgery 3. Ahmad Tanzeel, Anwar Mohd. 1993; 14: 184. Clinical importance of leech therapy. 16. http://en.wikipedia.org (Cited 16 IJTK2009; 8(3):443-445. November 2012) 4. Jordon EL, Verma PS. Invertebrate 17. Giacometti. Leeching in the Zoology. New Delhi: S. Chand & twentieth century. The American Company Ltd.; 2002: 564-66. journal of cardiology 1987; 60: 1130. 5. Brown FA. Selected Invertebrates 18. Kreaner BA, Korber KE, Aquino TI, Types. Tokyo: Toppan Company Engleman A. Use of leeches in Ltd; 1950: 303-04. plastic and reconstructive surgeries-

International Journal of Health Sciences & Research (www.ijhsr.org) 82 Vol.3; Issue: 7; July 2013

A review. J Reconst microsurg 1988; CCRUM) New Delhi: CCRUM; 4:381-386. 2005: 229. 19. Weinfield AB et al. Clinical and 27. Ahmad SD. Khazainul Mulook. Scientific consideration in leech Vol.1. Matba Nizami; 1314HJ: 329- therapy for the management of acute 30. venous congestion- a review. Ann 28. Vohra SB, Khan SY. Animal origin Plast Surg 2000;45: 207-212. drugs used in Unani medicine.New 20. Handerson HP et al. Avulsion of the Delhi; Vikas Publishing house. 1979: scalp treated by microvascular 6,52,58,64.96,121. repair- the use of leeches for post- 29. Michalsen Andreas et al. operative decongestion. Br. J. Plast Effectiveness of leech therapy in Surg 1983; 36:236-37. osteoarthritis of the knee. Ann Intern 21. Ibn Sina. A Treatise on the Canon of Med 2003; 139: 724-730. Medicine of Avicenna. Part 4. 30. Srivastava Anurag, Sharma Ridhima. (English Trans. By Gruner OC) A brief review on applications of London; Luzac & Co; 1930: 1037- leech therapy. Arch. Apll. Sci. Res. 45. 2010; 2 (2): 271-274. 22. Zahrawi AQ. Jarahiyate Zahrawi. 31. Haycox CL. Indications and Kanpur: Hindustani press; 1947: complications of medicinal leech 187. therapy. J Am Acad Dermatol 1995; 23. Godfrey K. Uses of Leech and leech 33(6): 1053-55. saliva in clinical practice. Nursing 32. Vrisco, PA Clat, K.V Ness, et al, time 1997. 62-63. Effect of thrombin inhibition on 24. Kaestner A. Invertebrate Zoology. synovial inflammation in antigen Vol.1. New York: Interscience induced arthritis. Ann. Rheum. Publishers; 1967: 541-63. Dis.2000; 59:781-87. 25. Medicinal leech. www.leeches.biz 33. Lone AH, Ahmad T, Naiyar AH. (Cited 20 March 2012) Clinical evaluation of leech therapy 26. Ibn Hubal. Kitabul Mukhtarat Fil in the management of knee Tib. Vol.2. (Urdu Trans. By osteoarthritis: A pilot study. J Clin Rheumatol Ayurveda, Jan-Jun 2011.

How to cite this article: Itrat M, Zarnigar, Haque N. Historical aspects of leech therapy: a critical review. Int J Health Sci Res. 2013;3(7):78-83.

************************

International Journal of Health Sciences & Research (www.ijhsr.org) 83 Vol.3; Issue: 7; July 2013