Leech therapy (Jalaukavacharana)-A gift of ayurveda for treatment of medico-surgical diseases

Saxena Varsha1, Srivastava Niraj*2, Kumar Pradeep3 1Department of Shalya-Tantra, Main campus, Uttarakhand Ayurveda University (UAU), Dehradun, Uttarakhand, India 2Department of Kaumarbhritya / Bal-Roga, Sardar Patel Institute of Ayurvedic Medical Sciences & Research Centre. Lucknow, Uttar Pradesh. Pin code226002, India 3Department of Shalya-Tantra, Faculty of Ayurveda, Institute of medical sciences Banaras Hindu University, Varanasi (U.P), India


INTRODUCTION
Ayurveda is a system of medicine with historical roots in the Indian subcontinent and has been practised around 6,000 years ago. Leech therapy (Jalaukavacharana) has been used to treat various diseases through Raktmokshan, a para surgical procedure in the surgical stream of Ayurveda. Leech sucks only impure blood. So, leech therapy is considered as blood puri ication therapy. Sushruta Samhita is the treatise of surgery in which "Jalaukavacharniya" is one of its chapters. Everything about Jalauka and its application has been scienti ically described (Yadavji and Acharya, 2009a). Jalaukavacharana forms by the addition of two words: Jalauka and Avacharana. Jalaukavacharana means the application of Leeches.The name 'leech' is derived from "laece," an old English word for physician (Davis and Appel, 1979;Irish et al., 2000). The therapeutic application of Leech is practiced among the other system of medicine, such as in Unani and Siddha also (Periyasami et al., 2018).Leeches were named Hirudo medicinalis in 1758 by Linnaeus (Mory et al., 2000) . Jalauka (Leech)is a segmented worm of Phylum Annelida. Leech is found in high quality in freshwater ponds of India (Vaibhava et al., 2016) . The treatment of disease with medicinal leeches is also known as Hirudotherapy (H.T.) (Whitaker et al., 2003).
In Modern medical sciences, leech therapy began in the 1960s, because of the practical results in plastic and reconstructive surgery for postoperative venous congestion and graft rejections treatment. The bio-active substances found in Leech's saliva, commonly known as "Hirudo substances" are also called Salivary Glands Secretion (SGS). Salivary Glands Secretion (Saliva) contains more than 120 bioactive substances, potent anticoagulant, vasodilator anesthetic, bacteriostatic, antiin lammatory, and analgesicproperties; some of them are still being examined. Haycraft (1984) discovered "hirudin," which is the most important component (Field, 1991). Leech should be removed when the patient feels pricking pain and itching over the bite because initially, leeches suck the impure blood then the pure.

Aim
The article aims to review and discuss leech therapy, its procedures, and research works done over a few decades in the ield of leech application in different diseases.
Leech therapy is widely used in modern medicine for treating a variety of challenging medical and surgical conditions such as plastic surgery (Henderson et al., 1983) , Arthritis (Osteoarthritis and Rheumatoid Arthritis) (Ahmad and Anwar, 2009) , Venous congestion (Weinfeld et al., 2000) , Vascular diseases (Pospelova and Barnaulov, 2010), Thrombophlebitis, etc.

Material Required for Leech therapy
1. Two small glass jars, kidney tray, one big bowl.

Purva Karma (Pre-Procedure Protocols)
In Purvakarma, mainly Snehana (oleation) and Swedana (sudation) of the patient is done and cleaning of part of the body to which Leech is going to be applied. For leeches to suck the maximum amount of blood very quickly without any problem, they must be stimulated and energized. This is done by using the paste of mustard and turmeric powder on the body of Leech or drop leeches in the water containing turmeric powder, and it is found that an inactive leech becomes active Figure 2.

Pradhana Karma (Main Procedure Protocols)
Main procedures are completed in the following steps-1. Before the application of leeches, the patient's affected part is cleaned and sterilised with boiled warm water.
2. First, Shodhita (Clean) of the leeches is done by putting them in turmeric mixed water for 15 minutes and keep in plain water for 5 minutes.
3. Then adequate numbers of leeches applied to the area of maximal congestion one by one Figure 3. 4. Once the leeches are positioned, it will remain safely in place until fully distended and then detaches spontaneously. (30-50 mm.) 5. The blood is allowed to ooze out for 20-25 minutes.
6. Leeches should again be placed on the patient every 4th day or as required.
7. So a maximum of ive times leeches may be placed to a single patient.

Paschatya-Karma (Post-Procedure Protocols)
1. The leech/leeches fall away after drawing blood (Jaluakas), and when leeches fall apart, its body should be massaged with rice powder, and its mouth should be massaged with oil and salt and gently squeezed till signs of proper vomiting appear Figure 4.
2. The properly vomited one should be placed as before in glass jar.
3. The water of glass jar should be chlorinated and replaced after six days.

Amount of blood sucked by Leech
1. In-person who is reliable has an excellent accumulation of Doshas and has suitable age (more than 16 and less than 70 years of age) after Vaman, Virechana, one Prastha (Thirteen and a half pal i.e., 540 ml) of blood may be allowed to low out.
2. For calculating the amount of blood sucked, leeches should be weighed before and after application.

Bite of the Leech during leech therapy
After detachment of Leech, it leaves the "Y" shape bite mark on the skin surface with its smaller anterior sucker Figure 5. The leech saliva is illed with a chemical that contains a painkiller and Anesthetics substance, which stops you from feeling the bite. (Michalsen et al., 2007).

OBSERVATION AND RESULT
Various published articles on "application of leech therapy (Jalaukavacharana) on various diseases" and "Hirudotherapy (H.T.) in various diseases" were studied and analyzed according to the aim of the study. A total of eight publications was included in the inal selection after systematic analysis. Medicinal Leech is a small "factory" manufacturing many biologically active substances. Leech saliva contains more than 120 compounds that exert positive effects in the host's body Table 1.

Leech therapy in Deep vein thrombosis
Deep vein thrombosis (DVT) is a semisolid clot in the vein, which has more chance to develop pulmonary embolism due to thrombosis formation in the calf muscle (Das, 2016). Leech therapy is very effective in DVT because the saliva of Leech contains many bio-active substances like HirudinHirudin, calin, factor Xa inhibitor, which hampers the coagulation of blood. Leech dissolves clots of blood by its thrombolytic effect. Leech saliva contains three compounds that act as a vasodilator agent like Acetylcholine etc. The saliva of leeches also includes an aesthetic substance. All compounds work together to decrease blood viscosity, making a thinner consistency of blood to promote better low (Kaur et al., 2015).

Leech therapy in Non-healing ulcer
Leech saliva provides Carboxypeptidase that is an inhibitor enzyme to cure ulcer area, which reduces vascular congestion. Leech saliva has Histamine like substances and Acetylcholine like substances. These substances act as peripheral vasodilator effects, improves blood circulation, and manage ischemia around the wound, thus promotes wound healing (Neelofer et al., 2018).

Leech therapy in Abscess (Vidradhi)
Vidradhi is a clinical condition that can spread in lammation of skin & subcutaneous tissue. In the modern system of medicine, there is no alternative to antibiotic and anti-in lammatory drugs to manage in lammation. Some leech saliva compounds such as Bdellin, etc. have an anti-in lammatory effect which inhibits trypsin, plasmin, and acrosin (Eldor et al., 1996). Ayurveda says that the Jalaukavacharana's mode of action is effective in managing in lammation due to its capacity to remove Rakta Dhatu and Pitta Doshas.

Leech therapy in Micro-vascular & Reconstructive Surgery
Micro-vascular reconstructive surgery involves the relocation of autogenously vascularised tissues to renovate extensive tissue defects. It has been used by different specialists today, like plastic surgery, gynecological surgery, general surgery, ophthalmoscopy surgery, neurosurgery, etc. Leeches are used to reduce the congestion by removing blood that can't exit via the venous system (Mutimer et al., 1987) Leeches are also used in skin lap transplantations, which help inadequate blood supply to the lap and healing process of the skin graft (Deganc  It is potent aticoagulant (blood thinner) and inhibits blood coagulation by binding to thrombin. (Eldor et al., 1996) Calin Calin mainly blocks the binding of the Von Willebrand factor to collagen; thus, it is conducive to inhibit blood coagulation. (Munro et al., 1991) Destabilase It will have thrombolytic effects that dissolve ibrin (Zavalova et al., 2000) Hirustasin It Inhibits kallikrein, trypsin, and chymotrypsin. (Sawyer, 1986) Hyaluronidase Antibiotic property increases the permeability of the host skin (spreading factor) effective in joint pain. (Adams, 1988)

Factor Xa inhibitor
Suppresses the activity of the Xa coagulation factor and effective in the treatment of joint disorders such as Osteoarthritis and Rheumatoid arthritis. (Hofmann et al., 1992).

Carboxypeptidase' A inhibitors
Increases in the in low of blood at the bite site (Reverter et al., 1998).

Leech therapy in arthritis
In the saliva of Leech, several components are available which have an anti-in lammatory effect, anesthetic effect, and vasodilator effect, which are needed for the treatment of arthritis. Anti-in lammatory compounds are bdelins and eglins (Abdullah et al., 2012),and vasodilator compounds are histamine-like substances and Acetylcholine that have an essential role during the treatment of Osteo-arthritis and Rheumatoid arthritis. Vasodilator compounds help to dilate the vessels and increase blood low, consequently removing compounds from the site, relieving pain, and in lammation. So Leech is instrumental in osteoarthritis and rheumatoid arthritis (Eldor et al., 1996).

Leech therapy in cardiovascular
Cardiovascular diseases are mainly related to the heart, veins, and arteries. Leech saliva contains and HirudinHirudin, Calin, and thrombin inhibitors, which improve blood low through anticoagulation, thrombolytic, and antiplatelet activity. (Weinfeld et al., 2000;Munro et al., 1991). Blood can thicken, which makes it prone to clot formation and an increase in blood pressure individual. These clots can cause a stroke or heart attack. Many studies exposed that Hirudin is more effective than heparin in preventing deep venous thrombosis (DVT) and cardio-vascular patients with unstable angina (Ángeles Corral-Rodríguez et al., 2010).

The complication of leech therapy
In Ayurveda, no speci ic complications are mentioned, but some dif iculty of Raktamokshana such as Paka (in lammation) and Daha (burning sensation) can occur (Yadavji and Acharya, 2009c), but modern science mentioned many complications after leech therapy such as 1. Excessive bleeding can occur with leech therapy; it can be controlled by applying direct pressure or topical thrombin (Whitaker et al., 2003). Excessive blood loss may necessitate blood transfusion, so patients should be informed of the possibility (Chepeha et al., 2002).

A. hydrophila causes the most common infections involving leech therapy, infections with
Serratia marcescens, A. sobria, and Vibrio luvialis have been reported (Ardehali et al., 2006) .Infections can arise within 2 to 11 days after leech therapy. Consequently, it can result in abscesses and cellulitis, which can inally progress to sepsis (Abdelgabar and Bhowmick, 2003) .

CONCLUSION
Jalaukavacharan (Leech therapy) is an ancient Ayurvedic bloodletting technique which has the great potential to manage ischemic, in lammatory, and infective disease by removing the blood in the deep-seated regions. The saliva of Leech contains numerous bioactive constituents which possess analgesic, anti-in lammatory antiseptic & antibacterial property, etc. Leech therapy is useful in the ield of plastic surgery, Arthritis (Osteoarthritis and Rheumatoid Arthritis), Venous congestion, Varicose veins,Hemorrhoids vascular diseases, Thrombophlebitis, cellulitis, sciatica, in lammatory reactions, blood puri ication, ischemic heart disease, and hypertension. It is expected to be of paramount importance due to the ease of leech application and minimum side-effect. Leech therapy has Ayurvedic origin, but it is acknowledged by modern medicine due to its effectiveness in healing various kinds of diseases. It is also considered as wonder therapy.