Correspondence Address:
V D Mahanta
Department of Shalya Tantra, All India Institute of Ayurveda, New Delhi
India

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Introduction: Ayurveda explains a wide range of factors in the manifestation of Vrana like Abhighata (physical trauma), exposure to Amla dravya (chemical), Kita damsa (insect bite) etc.^[1]

On accidental exposure, Kitas (insects) emit poisonous substances into the blood through saliva and cause formation of Vrana (ulcer) and Sopha (inflammation) at the site of bite. If appropriate interventions are not taken at right time; other generalized reactions like Toda (burning pain), Paka (suppuration), Shotha (swelling), Vaivarnya (discoloured skin), Vrana kledana (foul discharge from ulcer), Ruja (pain), Jwara (pyrexia) etc. will manifest.^[2]

Insect bite and sting cases are commonly seen in rural clinical practice. Venom is composed of proteins and other substances, which is responsible in developing allergic reactions of various stages depending upon the nature of the venom as well as patient’s resistance power. Initially burning pain and redness appears followed by gradual localized swelling. There may be presence of visible sting or a small puncture at the site of bite. The bites may cause manifestations like acute generalized exanthematous pustulosis (AGEP) or toxic pustuloderma, anaphylactic reaction etc.^[3] In routine; rest to the affected part, application of ice packs, compression and elevation of the affected part etc. are advised to reduce inflammation and pain. In addition, other medications like anti-allergic drugs, anti- inflammatory drugs, antibiotics etc are also recommended to combat symptoms.

Exclusive description of wound and its management can be observed in the texts of Ayurveda. Specifically, Rakta mokshana (blood-letting) through Jalauka (Leech) is emphasized in the management of Savisaja vrana (poisonous wound).^[1] Various clinical studies have reported rapid, effective and long-lasting potential of leech application in managing painful conditions.^[4]

Case report: A 45 years old male auto driver of Vata kaphaja prakriti visited OPD of Shalya tantra, Institute for Post Graduate Teaching and Research in Ayurveda, Gujarat Ayurved University, Jamnagar with complaints of severe pain, swelling with ulceration over the dorsum of right foot and intermittent fever for the past two weeks. History revealed an unknown insect bite during sleep. Burning pain was noticed immediately after the bite that was increased gradually. On 2^nd day, affected foot was swollen with symptoms of cellulitis. Patient had taken antibiotics, analgesics and anti-allergic drugs for ten days from a private hospital. He did not get relief and the severity of pain, size of ulcerative lesion was increased. Routine laboratory investigations were normal except slight variation on percentage of neutrophil and lymphocyte count.

On local examination, a progressive ulcer at dorsum of left foot just above the meta-tarso-phallangeal joint, about 5x7 cm in size, with irregular, inflamed margins was found. Floor was covered with necrotic tissue with foul smell and purulent discharge [Figure 1]. On palpation, local temperature was raised and the surrounding area was tender (+++). Distal neurovascular status was normal. Radiological examination of foot revealed no bony abnormality. Based upon the signs and symptoms; case was diagnosed as Dushta vrana due to insect bite and planned for Jalaukaavacharana (leech application).{Figure 1}

Before application of Jalauka, necrotic tissue was removed surgically and surrounding skin of the ulcer was cleaned with Panchavalkala kwatha [decoction of barks of five trees i.e. Vata (Ficus bangalensis Linn.), Udumbara (Ficus glomerata Roxb.), Ashwattha (Ficus religiosa Linn.), Parisha (Thespesia populnea Solan ex Correa), and Plaksha (Ficus lacor Buch-Ham.)].

Jalaukas were applied over the floor and at the border of the ulcer [Figure 2]. Jalaukaavacharana was started with four Jalauka on first day and three Jalauka on 3^rd and 5^th day of admission [Figure 3],[Figure 4]. This was followed by cleaning of the area with Panchavalkala kwatha and dressing with paste of Katupila (Securinega leucopyrus [Willd.] Muell) and Tila taila (sesame oil) regularly till complete healing. All the Jalaukas used on 1^st day were died after 15 minutes of blood-letting, while Jalaukas used on 3^rd and 5^th day were died after an hour.{Figure 2}{Figure 3}{Figure 4}

Observations: Swelling and pain were reduced remarkably on 5^th day of leech application. On 15^th day of regular dressing; necrotic tissue disappeared completely and wound became clean with exposed tendons [Figure 5]. After 30 days, healthy granulation tissue was observed and exposed tendons were covered with healthy granulation tissue [Figure 6]. Gradually, the ulcer size was reduced with remarkable wound contraction. After 45 days, the wound became small and wound was healed completely by the end of two months [Figure 7],[Figure 8],[Figure 9],[Figure 10] without any internal medication.{Figure 5}{Figure 6}{Figure 7}{Figure 8}{Figure 9}{Figure 10}



Discussion: About 67 varieties of Kitas (insects) are mentioned in the classics of Ayurveda. The group of Tikshna Kita produces severe cutaneous reactions in form of Sopha (inflammatory lesions), Granthi (swellings), Pidakas (vesicles) and other systemic manifestations like Jwara (fever), Daha (burning pain), Angamarda (bodyache), Murchchha (anaphylactic reactions) etc. by virtue of their Ushna (hot), Tikshna (sharp), Shukshma (penetrating into minute channels of the body), Vyavayi (rapidly permeating into the whole body), Avipaki (disturbing the tissue metabolism) etc. characters.^[5] Due to Ushna guna; Kita visha vitiates Rakta and Pitta dosha and produces Daha, Sopha at the local site. Being dry in nature, it causes pain by vitiating the Vata. Shukshma guna probably takes the poisons to the deeper tissues and by spreading it causes cellulites.

In modern dermatology, these reactions are found when body comes in contact with offended arthropods that produce injury to the skin in a variety of mechanisms.^[6] Mites are also considered as aetiological factors in the manifestation of dermatological reactions. Contact may cause erythematous papules, pruritus and formation of vesicles etc.^[7]

Raktamokshana is being practiced in India since long in the management of Dusta vrana (infected wounds), Granthi (cystic lesions), Arbuda (Neo Plasm) etc. Jalaukaavacharana is one type of Raktamokshana that counters vitiated Rakta and Pitta. After piercing the skin, leech sucks the blood and injects number of biological substances into the blood stream. A medium size leech sucks 5-15ml of blood in one sitting.^[8] In this study, approximately 7-8 cm size leeches were used and they consumed 10-15 ml of blood in each sitting. As, leeches sucked vitiated Rakta dosa (blood with toxins and unwanted metabolites) from the site of ulcer; reduction in pain and inflammatory signs were noticed.

Patient was reported reduction in pain suggesting poisonous substances might have been removed through the blood by leeches. The inborn quality of Jalauka i.e. Shita (cold) and Madhura (sweet) are opposite to Pitta dosa and these qualities might help in pacifying vitiated Pitta.^[9] Hirudin, Hyaluronidase, Kallikrein, Histamine, Collagenase, Bdellins, Eglins present in saliva of leech possesses activity of wound healing. Hirudin is capable to increase surface perfusion due to its anti-coagulation effect. Presence of Histamine, a vasodilator constituent improves blood circulation by dilating capillary bed in that area and might help in flushing out of the unwanted substances from the ulcer. Thus, possibly cellulites was controlled. Other substances like hyaluronidase, bdellins, eglins possesses anti-inflammatory and anti- biotic properties. All these in combination, possibly played a great role in controlling inflammation and helped in wound healing.^{[10],[11],[12]}

Panchavalkala kashaya helps in wound healing by the virtue of its Kashaya rasa (astringent taste),^[13] that brings back the Vrana to Shudhha avastha (clean stage) besides checking excessive discharge.^[14] Paste of Katupila with Tila taila is traditionally in use for dressing wounds and its wound healing efficacy is reported.^[15] Snigdha guna of Tila taila helps in facilitating the process of overall wound healing.

It is observed that the progressive phase of ulcer was managed successfully by three sittings of Jalaukavacharana and regular dressing with paste of Katupila and Tila taila. No other medicines were used during the course of treatment.

Conclusion: Jalaukavacharana along with local application of paste of Katupila mixed with Tila taila is an effective and safe treatment modality for the management of Dusta vrana caused by insect bite. This modality may even be beneficial in other types of infective and non- healing ulcers. However, such usefulness needs to be evaluated through well-defined clinical trials.

Source of support: Institute for Post Graduate Teaching and Research in Ayurveda, Gujarat Ayurved University, Jamnagar - 361008, Gujarat, India.

Conflicts of interest: None declared.

References