A CLINICAL SUCCESS IN THE MANAGEMENT OF KOTHA (DIGITAL GANGRENE) BY LEECH THERAPYANDPANCHTIKTAGHRITAGUGGULU - A SINGLE CASE STUDY

Symptoms may include a change in feet and are This may arise of or other conditions, majorly and its amputations are challenging, but Ayurveda offers therapy options. In Ayurveda, gangrene can be considered as Kotha under DushtaVrana due to Margavarana and Dhatu This case study aims to investigate whether Ayurvedic intervention can manage Kotha (gangrene) without amputation of the gangrenous part. Here a case report disscused diagnosed with kotha(Dry Gangrene) treated with Ayurvedmanagenment,Panchtiktaghritagugguluoral and Jalaukavacharana (leech therapy), whichwere found very effective and safe in a patient of dry gangrene.

Gangrene is a general term that can be used to describe a number of conditions that involve death and subsequent decay of the tissue in one regional portion of the body 1 . A complication of necrosis, gangrene can arise because of critically insufficient blood-supply 2 .Gangrene occurs when a body part loses its blood supply. Without a substantially functioning blood supply, the cells struggle to survive and ultimately die. This necrosis or cell death, can result when a portion of the body's tissues becomes infected, injured or constricted, interrupting the blood supply. There are several types of gangrene, but the three most common variations are wet, dry and gas gangrene. Less common variations include internal and Fournier's gangrene. Gangrene can involve any part of the body, but the most common sites include the toes, fingers, feet and hands 3 . Dry gangrene is a condition that involves tissue death and turns it dry, dark and mummified due to arterial occlusion. It occurs gradually, progresses slowly and affects the lower extremities of the body (toes and feet) due to insufficient blood supply to the tissues. Dry gangrene is very common in individuals suffering from arteriosclerosis, high cholesterol, diabetes and smoking 4 . In dry gangrene, due to necrosis, the tissue becomes shrunken and blackened and gets detached. In this condition, autoamputation is usually practiced due to occurrence of clear lines of demarcation. If dry gangrene is left untreated or treatment is delayed, it may progress to cause infections and complicate the condition. Following autoamputation practice also increases the painful phase and decreases the quality of life 5 . Dry gangrene is usually less severe than wet gangrene and may result in auto-amputation (i.e., spontaneous detachment from the body and elimination of a ISSN: 2320-5407 Int. J. Adv. Res. 9(08), 668-672 669 gangrenous part), whereas wet gangrene may lead to cellulitis, loss of the extremity, septicemia and death 6 .
In Ayurveda, gangrene can be considered as Kotha under DushtaVrana due to Margavarana and Dhatu Kshaya. Margavarana (encapsulation) and Dhatu Kshaya (depletion of Dhatu) are the two major causative comorbidities of VataVyadhi. The word Marga in general refers to any channels within the body, but, contextually, it refers to the vessels carrying the nutrients and Avarana means Avarodha and is translated as obstruction. Pathological probability of gangrene may be accumulation of morbid Kapha and Pitta Dosha within the channels that the momentum of the VataDosha circulation in the channels or impairment of momentum 7 . The influence of Margavarana is not limited proximal to the obstruction but distal to the obstruction, the circulation of the nutrients is affected and hence the body part distal to the obstruction is deprived of nutritionand hence suffers from pathology of Dhatu Kshaya 8 .
Leech therapy is becoming increasingly popular among practitioners of contemporary and alternative medicine. Many studies are currently under way to evaluate its effects, mainly in the treatment of pain 9 . In Europe and the United States, thousands of patients have been healed using leech therapy 10 . Many traditional medical systems, for example, the Greek, Arab, and Russian, mention leech usage 11 . The origins of traditional Indian medicine Ayurveda remain unclear, but it is said to date back some 3000 years. Leech therapy has been an active part of traditional Indian medicine throughout its historyPanchatiktaghritguggulu, reference from Bhaishjyaratnavalikushthrogadhikara 12 . which is combination of 5 drugs which has bitter taste (tiktarasatmaka). So probable mode of action of Panchatiktaghritaguggulu can be considered as, all properties of this drug acts on cellular level of skin decreasing Keratinization of skin layer thus improving cell cycle as a result of these symptoms like Itching, extensive patches, unctuous & raised red color of patches were reduced giving normal texture to skin.

Case Report
A 45-year-oldlady visited the Shalya Tantra outpatient department of Govt. AkhandanandAyurved Hospital, Ahmedabad with complaints of blackening, numbness, feeling of cold and moderate pain, with slight swelling near line of demarcation of the distal index, middle and ring finger of the left hand [Figures 1]. The above sign and symptoms were spreading to proximal part of the finger from more than 1 month. She had consulted modern medicine doctors for the treatment. Color Doppler, X-ray of the left hand and pathological investigations were done as per the advice of previous doctors. Color Doppler report showed color flow in middle and ring finger up to middle phalanx and no color flow in pulp/distal index finger and X-ray and pathology reports were normal. As per theupper limb arterial color doppler report, modern medicine doctors diagnosed it as gangrene of the distal index finger probably due to cellulitis, because it initially started with redness and pain in the distal part of the index finger, then gradually spread proximally with blackening and numbness. Modern medicine doctors advised surgical amputation as ultimate treatment. She opted alternative option for the same problem without surgical intervention.
After confirmation of Kotha (dry gangrene), Ayurvedic treatment consisting of PanchtiktaghritaGuggulu thrice a day before meal with water, and Jalaukavacharana was done for 6 weeks. The treatment intervention was selected on the basis of clinical presentation of the Kotha (dry gangrene) condition and therapeutic properties of the drug with possible ability to modify the same.The patient showed mild improvement after the 2nd week; therefore, the same medicines were continued every week and clinical improvements were observed Case Observation

Discussion:-
In the modern era, treatment of gangrene infections includes the removal of necrotic tissue in an attempt to allow healing of the surrounding living tissue. It is also an important step toward the prevention of further infection. The treatment options of the various types of gangrene, however, differ due to different types of conditions. In Ayurveda, gangrene can be considered as Kotha under DushtaVrana due to Margavarana (obstruction) andDhatu Kshaya. Margavarana is caused by imbalanced Tridosha. Panchtiktaghritaguggulu and Leech therapy combination aimed primarily at removing deepseatedPitta from the tissues. In Dhatu Kshaya (degenerative) condition at gangrenous part, it also acts to nourish and strengthen the system, supporting the overall health and proper function of the joints, the muscles and the connective tissue.
The main contents of this drug are Panchatiktaganadravyas, ghee&Guggulu. So probable mode of action of Panchatiktaghritaguggulu can be said as all contents are having tikta rasa, laghu and rukshguna, so it acts as antiitching property, kledand vikrutmedaupashoshan, vranashodhak 13 . It mainly acts on body wastes (kleda), meda(fat), 671 lasika (plasma), rakta (blood), pitta, swed (sweat) and shleshma 14 . Nimb (Azadirecta indica) has chemical composition of Nimbin, Nimbidin possesses significant dose dependant anti-inflammatory activity & significant anti-ulcer effect 15 .Guduchi (Tinospora cordifolia) having Berberin and tinosporin mainly acts as anti-oxidant & immune-potentiating thus cell layers during disease pathology are improved by this drug 16 . Vasa (Adhatodavasica) the Vascicinone has anti-histaminic property as well as it is anti-oxidant and antiinflammatory 17 . Patol (Trichosanthas dioica) has anti-oxidant 18 and Nidigdhika (Solanum xanthocarpum) has anti-histaminic property 19 . Guggulu (Commipheramukul) has excellent property to act on vikrutkleda (abnormal body wastes) and meda (fat), mamsa dhatu (flesh) as it has Katu,Tikta, Kashay, Madhur rasa, Ushnaveerya and katu Vipak 20 . Guggulu stimulates body activity to build up immune system. Ghrita has lipophilic action so helps in ion transportation to a target organ. This lipophilic nature of Ghrita facilitates entry of drug in to cell and its delivery to mitochondria and nuclear membrane. Also, it helps in restoring the normal texture to skin 21 . So, all these properties act mainly at cellular level of skin decreasing keratinization of cell layer thus improving cell cycle as a result symptom like itching, deranged complexion, unctuous, perspiration, white or red patches are reduced giving normal texture to skinLeeches act by secreting biologically active substances in their saliva. This saliva, which contains a hundred of so different substances, includes an antiplatelet aggregation factor, anaesthetic, and anti-inflammatory and antibiotic agents. Leech saliva also contains an anticoagulant, hirudin, which stops blood clotting and dissolves thrombi, clearing partial and complete blockages in distal arteries. When leeches bite, chemicals in their saliva dilate host`s blood vessels and thin their blood. Simultaneously secreting a local anaesthetic, mask any pain from the bite, rendering hosts unaware of leech presence. By ingesting excess blood, leeches reduce tissue swelling and promote healing. These micro-circulatory actions enable fresh oxygenated blood to reach host's affected areas prior to the restoration of the normal circulation 22 .

Conclusion:-
Ayurvedic management consisting of Panchtiktaghritaguggulu and leech application was found very effective and safe in the management of case of Kotha (dry gangrene). The observed benefits may be attributed due to antiallergic, antibacterial and blood-purifying properties, skin health promoter, detoxifying and anti-inflammatory action of Panchtiktaghritaguggulu. The findings of this case report suggest that with above Ayurvedic intervention Kotha (dry gangrene) may be managed without surgical intervention. The findings need to be confirmed and validated in more of a number of patients of gangrene