Jalaukāvacarana (Hirudo therapy) in the Management of Necrosed Index Finger due to Crush Injury

Abstract

Necrosis of tissue has become the challenging case, considering the difficulties of its management to bring back the normalcy of dead tissue. Treatment choice in surgery ends up with amputation of the affected part which leads to depression to a patient. In Ayurveda, posttraumatic necrosis can be correlated with picchita vrana (crushed injury) which is included under āgantuja vrana (traumatic injury). In this case report, an interesting case of posttraumatic necrotic changes of the right index finger was presented to us at the Outpatient Department of Ayurved Research Hospital. There was symptom of aggravated pain along with gradual discoloration of the tip of the index finger to a necrotic condition. Naturally, such cases have a very poor prognosis. Considering the pathological changes in this case, jalaukāvacarana (Hirudo therapy) procedure has been taken up for the management. In the 1^st week, three leeches were applied after every 3 days, and later on, after every 7 days, further three sittings of leech application were done. Leech absorbed impure blood which results in neovascularization and reconstruction of the necrotic tissue. Antiplatelet and antithrombin action of hirudin present in saliva of leech recanalizes the thrombus or clot at the injured part. The patient was cured completely and survived the finger from amputation with jalaukāvacarana (Hirudo therapy).

Introduction

In Ayurveda, crush injury can be correlated with picchita vrana, one kind of āgantu vrana (traumatic wounds) among six types.[¹] The treatment for picchita vrana includes śīta lepanam (cold application) which is the application of the drug as a plaster and also śītala pariṣeka (pouring cold medicine) which is rinsing off the affected part by drugs which has a cold potency for both of the procedure.[²] Necrosis of tissue due to crush injury is an acute condition, and the pain is more severe due to hampered blood circulation. Necrotic changes are usually caused by severe trauma, infection, and toxins. Due to the damage to blood vessels, there is disrupted blood supply to associated tissue which leads in the ischemia. Finally, it results in unregulated digestion of cell components which causes the cellular breakdown.[³] The other cause is the thermal effect that is extremely high or very low temperature can result in necrosis due to the disruption of cells.[³]

Necrosis begins with the changes in color, consistency, and adherence to the wound bed. Prolonged ischemia may lead to necrosis of underlying tissue producing area of gray and blue skin or white devitalized tissue. Depending upon the period of its ischemic changes, consistency of the tissue changes depends on its hydration.[⁴] As the severity increases, the color progresses brown to black. Basically, necrotic phenomena involving two process, the first one is the swelling in the cell which results in shrinkage and transpiration of the nucleus and finally the nucleus dissolves into the cytoplasm.[⁵]

In Ayurveda, this case comes under dhamanī praticchāya (vascular disorder), samprāpti (pathogenesis) of this case can be considered as involved tridoṣa (three body humors) due trauma that leads to saṅga (obstruction) of rakta (blood). raktamokṣana is a parasurgical procedure and indicated for the management of raktaj disorders (diseases due to vitiation of raktaja). Many research studies have been carried out under the efficacy of Jalauka to treat various kinds of skin disorder as well as nonhealing ulcer, which actually results in excellence.[^6-8] suśruta mentioned rakta as the fourth doṣa (humor possessed by the body), and the choice of treatment for such diseases is raktamokṣana. There are different methods of raktamokṣana such as jalaukāvacarana (Hirudo therapy), sirāvedha (bloodletting by vein section), śrṅga (bloodletting by cow horn), alābu (bloodletting by gourd), and pracchāna (scarification or scratching). Among these methods, the jalaukāvacarana is the best method due to it applicability in all individuals from pediatric to old age.[⁹] This is the first time in Indian medicine that suśruta mentioned the application of Jalauka (leeches – Hirudo medicinalis) for therapeutic purpose.[¹⁰] In the saliva of leech, there are many chemical enzymes; among them, hirudin is one having an anticoagulant and antithrombin action. Hence, in this case report, we decided to see the efficacy of leech application as it has potential to cure the blood-related disorders as mentioned in the classic.

Presenting complaints

A 40-year-old male patient, citizen of Gujarat, India, laborer in handling a machine (operator) as an occupation, visited our Outpatient Department (OPD) of Ayurved Research Hospital and had a complaint of severe pain and swelling at the index finger of the right hand. He was having difficulty in moving his index finger and disturbed sleep because of severe pain of the index finger. The patient reported that onset of this injury resulted from crushed injury before 1 month at his work place. He has never undergone any surgical interventions for his related case.

Clinical findings

There is no any significant systemic disease in the family which is relevant for influencing the recovery of his related problem. He did not have any addiction such as smoking, alcohol, and tobacco, except tea. The patient was fully conscious and oriented during the examination as well as the procedure. Before taking treatment at our hospital, he had gone to a superspecialty center for the treatment at a civil hospital, Ahmadabad, and was prescribed some medications (tablet pentoxifylline 400 mg 1 BD, tablet cilostazol 50 mg 2 BD, tablet acetylsalicylic acid 150 mg 1 BD, tablet ibuprofen 400 mg 1 TDS, and tablet pantoprazole 40 mg 1 BD). The patient had taken the medication for the last 20 days, but he did not felt any relief, especially for the pain that causes disturbed sleep for him, and finally, he had been advised to undergo amputation. Local finding showed blackish discoloration (necrotic changes) and inflammation on the tip of the index finger and nail bed was noted [Figure 1]. On palpation, local tenderness and mild temperature were felt while movement of the index finger was restricted and painful.

Figure 1: Necrosed index fingertip at first consultation in the outpatient department

Timeline

The detail about the treatment starting from day first to complete cure is mentioned in Table 1.

Table 1: The detail of the treatment date of the patient

Diagnostic focus and assessment

X-Ray of the palm was done and report showed no evidence of fracture and there was only soft-tissue edema in the terminal finger. Routine blood examinations were carried out and found within normal range. For further information, we had referred the patient to a local government hospital at Jamnagar for a second opinion, but from that hospital, the same opinion of amputation was given for him. Gangrenous necrosis can be considered a type of coagulative necrosis that resembles mummified tissue. It is characteristic of ischemia of the lower limb and the gastrointestinal tracts. If superimposed infection of dead tissues occurs, then liquefactive necrosis ensues (wet gangrene). At this stage, prognosis is very poor.

Therapeutic focus and assessment

The treatment that we had selected to manage this condition is jalaukāvacarana (Hirudo therapy). The materials used for the procedures were bowls, surgical gloves, turmeric powder (Curcuma longa), kidney tray, gauze piece, bandage, and disposable needle, which were kept ready. Jalauka (leeches) were put in the water mixed with turmeric powder for 2 min so that leech became active. The index finger was cleaned with normal saline and then dried up and rubbed with gauze piece. After wearing the surgical gloves, Jalauka was held at its center or nearer to the anterior sucker with the help of gauze piece. Then leeches were applied at the affected region or nearer to that. Leech started to bite at the applied skin spontaneously and started sucking of the blood. The patient experienced the slight pricking sensation at the site of the bite. Occasionally, leeches were so reluctant to bite and then small prick was made on the skin to ooze the blood. Once leech started to suck the blood, its neck part looks elevated that indicates that sucking is well and in progress. During sucking, gradual distention was observed at its body center and wavy movement/pulsation is visible throughout its body [Figure 2]. Then, the body part was covered with a wet swab except his mouth to create a natural atmosphere, and it was maintained throughout the process by pouring of some water on it.

Figure 2: jalaukāvacarana (applied three leeches) at the index finger

After removal of leeches, bite cite was cleaned with pañcavalkala kaṣāya and applied turmeric powder and tight bandaging was done to avoid the bleeding.[¹¹] When Jalauka give up automatically, then it was kept in a kidney tray and turmeric powder was sprinkled on its mouth. Jalauka automatically vomit the whole of ingested blood. Finally, leech was squeezed smoothly with the right hand to remove all the remnant parts of ingested blood from its body. It is very important to remove all ingested blood otherwise leech will die or get diseased as mentioned in classic.[¹²] Similarly, all the applied leeches had vomited and all used Jalauka were kept in clean vessel and water separately for the next sitting.

Follow-up and outcomes

jalaukāvacarana (Hirudo therapy) is a parasurgical procedure and applied in this case for six times till the completion of his treatment. In the first sitting, three leeches were applied and the above mentioned medications were continued. After the first sitting from the next day, all allopathic medications were stopped except analgesic. The severity of pain was reduced from grade 3 to grade 2 (pain assessment with Visual Analog Scale). Swelling was mild reduced, but sleep disturbance was as such so continued the analgesic two times a day. After 3 days again, three leeches were applied and about 15-ml bloodletting was done. The assessment was done on the 7^th day, and it was observed that pain was reduced from grade 2 to grade 1 and patient was free form severity of pain so he had sound sleep at night. On local examination, swelling was reduced remarkably and black coloration was reduced. Hence, we find the ray of hope that this case will be definitely cured. We continue the leech application on the 7^th day as the third sitting and then on the 15^th day as the fourth sitting. On the 15^th day, the patient was free from pain, swelling, and able to sleep at night calmly. The necrosed area was reduced and localized as well as the movement of figure was free and painless. The necrosis was localized toward the distal part of the figure [Figure 3]. Hence, after the fourth sitting, the patient felt relieved enough and got discharged from our hospital. It was observed that the patient had relief in symptoms like relief in pain and increased the range of finger movement. Patient also reported sound sleep. Pain as well as the swelling was reduced constantly day by day. The blackish discoloration slowly showed improvement toward the vascularization and changes toward the normal appearance of skin color [Figure 4]. The leech application was continued as the fifth sitting on the 22^nd day and the sixth sitting on the 30th day. After that it was observed 80% improvement in sign and symptoms and the finger appears almost normal [Figure 5]. Finally, the finger became normal and saves from amputation, deformity, and handicap. The finger was normal looking after removal of the necrosed part and normal tissue regeneration [Figure 6].

Figure 3: After 7 days (third sitting) reduced inflammation and necrosis

Figure 4: After 15 days (fourth sitting) localized necrosis and without swelling

Figure 5: After 22 days (fifth sitting) disappeared all necroses

Figure 6: After 1 month (sixth sitting) with normal finger

Discussion

There is no doubt that the allopathic management of the necrosis condition is quite helpful in the process of prevention of further destruction of the tissues and regaining the normalcy of its functional as well as anatomical of the necrosed tissues. The things to be discussed through this case is the quick result of the recovery of the patient who had taken the previous allopathic treatment (tablet pentoxifylline 400 mg 1 BD, tablet cilostazol 50 mg 2 BD, tablet acetylsalicylic acid 150 mg 1 BD, tablet ibuprofen 400 mg 1 TDS, and tablet pantoprazole 40 mg 1 BD). However, the day after Jalauka (leech) was applied, the patient found immediate relieved, mainly from the pain and localized edema which was causing him to have insomnia. We have stopped all the allopathic medications on the 8^th day of admission at our hospital.

Jalauka have been found to secrete saliva containing about 60 different proteins. These achieve a wide variety of goals useful to the leech as it feeds, helping to keep the blood in liquid form and increasing blood flow to the affected area. Several of these secreted proteins serve as anticoagulants (hirudin), which prevent or dissolve the formation of clots and thrombi in the necrotic cases.[¹³] Saliva of the Jalauka also contains platelet aggregation inhibitors such as apyrase, collagenase, and calin.[¹⁴] These proteins are helpful to control further thrombus formation in this case. They also helpful to dilate the blood vessels so that the nourishment of the affected tissue takes place.

The changes of neovascularization and regeneration of the tissue were observed from the second sitting of jalaukāvacarana (Hirudo therapy). The discoloration and edema present at index finger before the treatment gradually disappeared along with complete pain relief on fifth sitting of leech application. By the sixth sitting, the necrosed tissue was completely invisible leaving the healthy appearance of tissue without any symptom. In this case, no allergy or complication developed after application of leeches and the patient cured uneventfully.

Conclusion

The study concluded that jalaukāvacarana (Hirudo therapy) is a safe, effective, easy-to-apply, OPD parasurgical and nonpharmacological procedure in the management of necrosis due to crush injury. The take-home message through this case report is need to further study in more number of patients in collaboration with a vascular surgeon so that we can save the amputations. This report will be base for new researchers/scholars of Ayurveda for further study in this area.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Acknowledgement

Prof. Anup Thakar, Director ITRA, Jamnagar.