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GLORIOUS PAST RETURN?

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Journal of Medicine and Health Research
2(3): 97-105, 2017

HIRUDOTHERAPY: WILL THE GLORIOUS PAST RETURN?

VINEET NAIR1*, KRISHNA PADA DAS2 AND NAIRITA SAHA3

1
Department of Periodontology, North Bengal Dental College and Hospital, Darjeeling, India.
2
Department of Dentistry, National Medical College and Hospital, Kolkata, West Bengal, India.
3
Department of Oral Medicine and Radiology, North Bengal Dental College and Hospital, Darjeeling, India.

AUTHORS’ CONTRIBUTIONS
This work was carried out in collaboration between all authors. Author VN designed the study, performed the
statistical analysis, wrote the protocol and wrote the first draft of the manuscript. Authors KPD and NS managed
the analyses of the study. Author NS managed the literature searches. All authors read and approved the final
manuscript.

Received: 27th June 2017

Accepted: 28th August 2017
Published: 30th August 2017 Review Article
__________________________________________________________________________________

ABSTRACT

Hirudotherapy or leech therapy is a practice that dates back to the ancient ages, where it was employed as an
alternative to phlebotomy. However, it has now made a space for itself in today’s modern world therapy after
the discovery of several medicinal substances in its saliva which have anti-inflammatory, analgesic, antiseptic,
anti-metastatic, anaesthetic, anti-coagulant properties and several other effects. Although the procedure is not
risk free, no serious outcomes have been reported in studies till date. Now, scientists are on the verge of
developing a mechanical device, which could act as a leech. This review article on leech therapy covers 100
references spanning from 1854-2014 AD and was compiled after scanning all major scientific search engines
and also in the classical textbooks of Unani medicine.

Keywords: Annelid; hirudin; Hirudo medicinalis; leech therapy; Talīq.

1. INTRODUCTION relieving congestion and removing the noxious

Hirudotherapy (also known as leech therapy) is a
Latin term for a non-invasive treatment modality
using medicinal leeches on the body surface as
therapy for certain diseases [1,2]. The word ‘leech’ is
supposed to be derived from an old English word for
physician, ‘laece’ [3]. Leech therapy has been
administered since ancient times [4]. A painting in an
Egyptian tomb from around 1500 BC depicts the use
of medicinal leeches [5,6]. Ancient physicians of India
have been the strong proponents of talīq (leech
therapy) due to the numerous benefits it offered in a
range of local and systemic diseases [7-9]. The
benefits of leech therapy were earlier thought to be
derived from the amount of blood lost, hence
_____________________________________________________________________________________________________
humors [10]. However recent researches have
demonstrated that it is the leech’s salivary secretions
which contain an amazing cocktail of medicinal
substances which justify its therapeutic use in
numerous medical and surgical conditions like
phlebitis, varicosities, various skin diseases like
scabies, psoriasis, ringworm; to reduce post-operative
swelling in plastic and reconstructive surgery and pain
relief in various arthritic diseases [11-13]. In July
2004, the FDA approved leeches as a medical device
in the area of plastic and reconstructive surgery [14].
Now, scientists are on the verge of developing a
mechanical device, which could act as a leech and
thus reduce some of the risks [15]. The aim of this
article is to showcase these roles of leech therapy and

*Corresponding author: Email: drvineet_nair@yahoo.co.in;


to throw a query to its readers as to ‘will the glorious
past return?’
2. ABOUT THE LEECHES
The most widely used medicinal leech (Hirudo
medicinalis) belongs to phylum Annelida, class
Clitellata and subclass Hirudinea [16]. Other
medicinal leeches include Hirudo decora, Hirudinaria
mannilensis, Hirudo nipponia, Hirudo verbena,
Hirudo orientalis, Haementaria depressa and
Hirudinaria granulose. The latter is an Indian fresh
water leech and is found abundantly in the states of
Tamil Nadu and Kerala [17].
The leech is a segmented annelid without an
exoskeleton, with a distinct ability to expand in size
three times its resting length. Medicinal leeches grow
upto 12 cms in length. They crawl using their larger
posterior sucker and bite with the smaller anterior
sucker, have a mouth with three jaws arranged in tri-
radiate fashion; each jaw having about 100 teeth each
[18]. Leeches can survive in the temperature range of
0ºC to 30ºC and breathe oxygen through their general
body surface. However, they are readily killed by
chlorine in water, even in low doses. Leeches secrete
a layer of mucous on their body surface under
stressful conditions; thus it may be used as an
indicator of stress [1].
Leech saliva contains an amazing cocktail of about a
hundred biologically active substances, ranging from
analgesics, anaesthetics, vasodilators, antiseptics, anti-
thrombotic substances and even several hormones.
Hirudin, a thrombin inhibitor, was the first compound
to be isolated in 1884 by Haycraft but named in 1904
by Jacoby [19,20]. Hyaluronidase found in leech’s
saliva modifies the permeability of connective tissue
through the hydrolysis of endoglucoronidic linkages
of hyaluronic acid. Another important compound is a
serine protease inhibitor, hirustatin. A protein similar
to it has been isolated from Haementeria ghiliani and
named ghilanten. These are potent specific Factor Xa
inhibitors [21]. A similar acting compound,
piguamerin, has been isolated from Korean medicinal
leech, Hirudo nipponia. Bdellins are proteinase
inhibitors while apyrase and decorsin are platelet
inhibitors, the latter derived from the American
medicinal leech, Macrobdella decorsa. Destabilase
shows combined enzymatic, non-enzymatic and
antibacterial activity [22]. Calin is a collagen inhibitor
and especially inhibits collagen induced platelet
aggregation [23]. Recent studies have revealed the
presence of histamine, serotonin and also certain
steroid hormones including cortisol, progesterone,
testosterone, estradiol and dehydroepiandrosterone.
Certain kininases have also been isolated from the
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Nair et al.; JOMAHR, 2(3): 97-105, 2017
leech saliva, which are possibly responsible for the
analgesic action [24]. The combined benefits obtained
from these substances are resolving effects, anti-
oedematous, correction of certain micro-vascular
disorders, increased immune system activity,
antiseptic and bacteriostatic activity, elimination of
hypoxia, pain relief, promotion of healing and many
other effects [25-29]. There is also evidence that leech
saliva may have a role in stimulating erythropoiesis
[30].
3. PROCEDURE
When properly attached, the leeches suck 5-50 ml of
blood over a period of 30 minutes to 2 hours, until
they are completely quenched, then drop off
spontaneously. The resulting wound continues to ooze
for the next 24 hours or so [1]. Leeches should never
be detached by force, nor by the application of
alcohol. If the leech has to be detached manually,
application of 5% topical cocaine is helpful, as it
paralyses the leech. Upon removal, the leeches should
be sacrificed in 70% alcohol [15]. If the leech crawls
into any orifice like throat, and attaches there, the
ancient Unani physicians recommended to feed lehsun
(Allium sativa bulb) to the patient or to give him
ferrous sulphate (3.5 gm) orally in a single dose. Then
ask the patient to open his mouth over a water filled
container. The drugs were thought to make the leech
thirsty and it drops into the water consequently [31].
A recent study stated that garlic methanolic extract
(600µg/ml) could paralyze and kill leeches in around
one hour time [32]. However, it is better to plug
nearby orifices with sterile gauze before applying
leeches.
4. ROLE OF LEECH IN UNANI MEDICINE
Medicinal leech application has been reported to be
successful in the management of massive post-
traumatic lingual swelling and thus reducing the
chances of acute airway emergency [33-36]. For
treating sanguineous diphtheria, Azam Khan advised
application of leeches on the neck and below both the
ears provided the patient was not weak or
malnourished. If the patient had difficulty in
swallowing, then he advised to apply the leeches on
the nape of the neck in young age patients [37].
According to Razi, application of leeches on the post-
auricular region is beneficial in migraine [38].
Application of leeches on the hip joint and on the
back has been described by Razi for relieving sciatic
pain and backache respectively [39]. According to Ibn
Sina, use of leeches on a gangrenous part may help in
restoring the tissues [40]. This action may be
attributed to its vasodilating effect and also the

hyaluronidase present in leech saliva which promotes
tissue penetration.
That leeches could be employed for relieving piles
was reported by Azam Khan. He advised applying
leeches on the lowest part of the sacrum, or around
the swellings or even on the pile mass. It was also
used in the treatment of anal fissure [41]. According
to Azam Khan, if an abscess is caused on the
umbilicus, then application of leeches around the
lesion may be done if the child is more than two
months old [41]. For drainage of stagnant secretions
in filariasis, leech therapy may be done on the heels,
after the patient had undergone istafragh (evacuation
of morbid humors) with medicines [41].
5. RECENT DEVELOPMENTS IN
HIRUDOTHERAPY
5.1 Cancers
Anti-metastatic activity has been studied in the
salivary extract of Haementaria ghilianii and
Haementaria officinalis [41-44]. Synthetic hirudin
similar to the hirudin obtained from H. medicinalis
has also been demonstrated to have efficacious anti-
metastatic activity in a wide range of malignant tumor
cells, such as pulmonary carcinoma, osteo-carcinoma,
breast carcinoma and leukaemia [45]. Ghilanten from
the salivary gland secretions of H. ghilianii has been
found to suppress metastasis of melanoma, lung
cancer, breast cancer and prostate cancer in animal
models. In a recent study, salivary extract from H.
mannilensis demonstrated significant cytotoxic
activity against human small cell lung cancer and also
a synergistic action with the anti-cancer drugs
Irinotecan and Carboplatin [46]. Kalender et al. 2010
stated that leech therapy shows symptomatic relief of
cancer pain [47]. Masaki I et al. reported using
medical leeches to relieve venous congestion of a free
forearm flap after reconstruction in a patient with
intraoral carcinoma [48].
5.2 Diabetes
In a recent study, the salivary extract of H.
mannilensis was found to have anti-hyperglycaemic
activity on subcutaneous injection in animal models
of diabetes. A synergistic effect was also observed
with insulin use [49]. Leech therapy has been found to
be effective in many studies for healing diabetes-
related foot ulcers and improving circulation to the
tissues [50,51]. The underlying mechanism is thought
to be a combination of removal of metabolic
substrates, acceleration of tissue remodelling,
changing the states of temperature, tissue
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Nair et al.; JOMAHR, 2(3): 97-105, 2017
oxygenation, pH, fluid dynamics and microorganisms
in the ulcers [52].
5.3 Arthritis
Leech therapy has shown better efficacy in the
treatment of osteo-arthritis when compared with
diclofenac. Some studies also proved that leech
therapy can reduce synovial inflammation, leading to
decreased pain and improvement in disability [53,54].
Similar effects have been observed in iliosacral joint
pain and cervicobrachialgia syndrome [12].
5.4 Plastic and Reconstructive Surgery
The role of hirudotherapy in plastic and
reconstructive/replantation surgery has been put
forward by several authors [55-58]. Venous
congestion leading to occlusion, thrombus formation,
stasis and tissue necrosis is the most feared
complication following microsurgery for replantation
of amputated parts or plastic surgery [59]. The leeches
not only drain the stagnant blood, but also create a
wound that continues to bleed for a few hours [60-63].
The vasodilatation and increased tissue perfusion also
enhances healing. The average duration of treatment
is about 7 days and ranges from 2-14 days in different
studies [12].
Hirudotherapy plays a role in penile replantation as
well [64]. The current approach to penile replantation
involves re-approximation of the urethra and corporal
bodies with microsurgical anastomosis of the dorsal
vein. However when microsurgery was not available,
non-microsurgical penile replantations were plagued
by skin loss, urethral strictures and fistulae, loss of
the glans penis and sensory deficits [65,66]. The
leeches maintained post-operative venous outflow and
thus made the non-microsurgical replantation a
success.
5.5 Dentistry
In 1817, Thomas Bell treated a case of an oro-antral
fistula with facial swelling with six leeches "applied
to the face” [67]. Chapin A Harris in 1839 used
leeches via tubes on gums for drainage of an abscess
[68]. Spencer Bate in 1854 treated grossly carious
maxillary central incisor using a leech attached to the
gingiva [69]. Leeches were used in the treatment of
many paediatric conditions, like teething [70]. In
treatment of gum diseases, leeches drain the
inflammation at the site of abscess. Anti-coagulating
agents increase blood flow to the gingiva, eliminating
toxins and increasing nutrition at the affected area
[71].

In the available literature, there are only a few works
that have evaluated the clinical efficacy of leech
therapy in exacerbations of chronic apical
periodontitis [72]. Elena (2003) noted that post
application of medicinal leeches, the severity of
spontaneous pain and pain on percussion, collateral
edema, hyperaemia and edema of the mucous
membrane of the alveolar process of the causative
tooth was reduced by 3 to 5 days and disappeared on
the 7-10th, whereas in patients without the use of leech
therapy, the symptoms persisted for 7 to 10 days.
Bone densitometry in patients with chronic apical
periodontitis who underwent hirudotherapy showed a
marked improvement in the periapical tissues
compared to the control group [73].
5.6 Antibiotic Activity
Four anti-bacterial peptides were found in the central
nervous system of leeches. Similar substances have
also been demonstrated in leech saliva in recent
studies [74]. A protease-inhibitor, gelin has been
identified in leech saliva having specific anti-bacterial
activity specifically against A. hydrophila. The action
of gelin is attributed to inhibition of human and
porcine leucocyte elastase and chymotrypsin [75].
5.7 Other Less Common Applications
In recent studies, extracts obtained from leeches have
demonstrated to have anti-narcotic, anti-stress and
anti-psoriatic activity [74]. Owing to the anti-
coagulant and anti-thrombotic actions of leech saliva,
it has been used in the treatment of certain
cardiovascular disorders like thrombophlebitis,
hypertension, varicose veins, haemorrhoids,
gonarthritis and secondary ischemia related
dermatosis [10,76-80].
The indications for using the leeches in gynaecology
are as follows- post labour’s endometritis,
parametritis, mastitis and all forms (acute, subacute
and chronic) of adnexitis [81]. The ophthalmologists
use leech to diagnose the mucular edema (Irving-
Gass’s syndrome). Acute neuritis and otic murmur in
chronic neuritis of auricular nerves, otitis media and
otitis external, frontitis, maxillary sinusitis, the
furunculi of nose and external acoustic meatus are
well tolerated to hirudotherapy [82-83].
The central nervous system of the leech has been
studied by several authors for the formation of new
synaptic connections by regenerating neurons [84-86].
Other more recent studies show the beneficial effects
of immune cells of the nervous system allowing a
functional and natural repair of the nerve chain after
injury. This precisely justifies the presence of immune
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cells producing anti-inflammatory mediators inducing
regenerative processes [87-90]. Moreover, these
studies demonstrate the great conservation of effector
molecules between leech and mammals, which is
important to justify the therapeutic efficacy of leech
molecules on humans.
6. POSSIBLE COMPLICATIONS
Several potential complications have been reported
following leech therapy, most of which are
preventable as they appear to be associated with
misuse, or abnormally bred or poorly cleaned animals
[91,92]. Infection with several bacterial species,
especially Aeromonas hydrophila and Aeromonas
veronii is the most commonly reported complication
in many studies, with the prevalence ranging from
2.4% to 20% [93-97]. These microorganisms are
present in the intestine of the leech and can cause
wound infection and in the most severe cases even
sepsis [98]. Leech application can also cause infection
with Mycobacterium marinum, which may result in
erysipelas and submucosal abscesses [99]. Vibrio
fluvialis infection has also been reported after
hirudotherapy [100]. Another commonly reported
complication is the occurrence of excessive bleeding
following leech therapy, which may be alarming at
times. The saliva of the leech contains hirudin, which
inhibits thrombin in the clotting process and
histamine-like substances which may cause
continuous bleeding. The bleeding caused is mainly
due to inhibition of platelet aggregation by leech
saliva and not due to coagulation changes [21]. A rare
complication of leech therapy is thrombotic
microangiopathy leading to acute renal failure [101].
Other possible complications are anaphylaxis, local
allergic reactions and mucosal synechiae [102].
Anaemia of the hypochromic type is a rare
complication which has been reported in a few cases
and is mostly caused by unrestricted application of
leeches for long periods of time or due to leech
infestation [103,104]. The contraindications for
hirudotherapy are haemophilia, haemorrhagic
diathesis, hypotension, anaemia and sepsis [105].
7. NECESSARY PRECAUTIONS
For preventing infections, it has been recommended to
restrict the use of leeches on tissues with arterial
perfusion, to minimize contamination of necrotic
tissue and use of prophylactic antibiotics [106].
Aeromonas spp. produce beta lactamase, so penicillins
and first generation cephalosporins are ineffective.
The organisms most often involved in hirudotherapy
associated bacterial infections are usually sensitive to
second and third generation cephalosporins,
aminoglycosides, chloramphenicol, fluoroquinolones

and trimethoprim [107]. Since leeches are a potential
vector of blood-borne infections, including HIV and
viral hepatitis, they should be procured from
appropriate sources [11].
8. MECHANICAL LEECH
Researchers led by head and neck surgeon Gregory
Hartig at the University of Wisconsin at Madison in
the United States, are developing a mechanical leech,
which has distinct advantages over its flesh-and-blood
counterpart. A device had been designed that can
deliver and disperse heparin better to compromised
tissues. The porous tip of the device is implanted
beneath the skin and it rotates to inhibit coagulation
further. Psychologically patients feel more
comfortable being attached to a machine than a live
creature [108].
9. CONCLUSION
Leech therapy has come a long way. The discovery of
several bio-active substances having curative
properties have turned the annelid into a valued
medical and surgical device. A big challenge taken up
in the recent years is the development of artificial
leeches. It remains to be observed whether such a
device can entirely replace the natural leech,
especially because all components of its saliva have
not been identified yet.
CONSENT
It is not applicable.
ETHICAL APPROVAL
It is not applicable.
COMPETING INTERESTS
Authors have declared that no competing interests
exist.
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