Discussion
As per a recent publication in WHO’s International Standard Terminologies on Siddha Medicine, Naala noi or Naalaka noiis the term used for disease of the veins (Term ID: ISMT.4.16.76). Due to the derangement of the vatham , there is obstruction of normal blood flow; stagnant blood results in the release of pro-inflammatory mediators; and white blood cell infiltration in the affected area leads to itching and hyperpigmentation of the skin. According to T.V.Sambasivam Pillai Dictionary, ulcer (punn) is classified into the following 22 types; neruppu punn (burns), mega punn(venereal ulcer), koruku punn (chancre), veditha punn(fissuring ulcer), azhar punn (inflamed ulcer), vellai punn (gonorrheal ulcer), aaraa punn (chronic ulcer), oduvu punn, kiranthi punn (syphilitic secondary rashes), ottu punn(contagious sore), kuzhi punn (deep sore or perforating ulcer),rasa punn (diabetic carbuncle), karappan punn (eczematous ulcer), parangi punn (syphilitic primary sore), vettu punn(incised wound), kaya punn (traumatic sore), azhi punn(sloughing sore), rasa vekkadu punn (ulcer caused by mercurial poisoning), puttru punn (fungal ulcer), vayitru punn(gastric ulcer), thulai punn/purai punn (sinus) and ari punn (rodent ulcer) (28). Another classification of 10 types of ulcers (punn ) as follows: saruma punn (dermatitis), athirvu punn (dermatitis traumatica), thee punn (dermatitis calorica),kulirchi punn (chill blains or frostbite), azhugu punn(dermatitis gangrenosa), nanju punn (dermatitis medicamentosa),veppu noi punn (exanthema), thinavu punn (pruritis and urticaria), kirandhi (venereal ulcer), and korukku punn(chancroid).
Varicose ulcers are common in middle-aged men who are doing long-standing work like watchmen, policemen, salespeople, etc. Chronic varicose veins always result in ulcer formation if left untreated. Treatment mode for the Naalavibatha punn (varicose ulcer) often varies depending on the severity of the ulcer. If the severity of the ulcer is high, it must be treated with surgical intervention (29). If a severe infection is present in the wound, modern medicine treats it with antibiotics and anti-fungal agents. Antibiotic use can cause many health issues in the gut, resulting in gut-related issues.
Surgery is the most common intervention in treating varicose veins in modern medicine. After surgery itself, smaller-to-major life-threatening bleeding can occur, and recurrent ulcer formation is also one of the worst complications of post-varicosectomy. In these types of cases, the patients had complaints of recurrent infection on the surgical sites and varicosity formation on recurrence in a short duration (30).
The patient, in this case report, complained of six years of dilated veins in the lower limbs of her right leg, swelling and itching above the right leg’s medial malleolus for six months, and three months of a small ulcer in the same location. On examination, the Venous Clinical Severity Score was found to be severe (VCS Score-20). The patient’s sleep was disturbed. According to all the above details, the condition was diagnosed as Naalavibatha punn (varicose ulcer).
The mode of action and selection of every Siddha drug is based on correcting or normalizing the deranged uyir thathu (vatham, azhal, and iyyam ) of that particular ailment. Vatham is the primary thathu that has been affected in Naalavibatha Punn ; the aggravated vatham was brought back to normal by the purgation therapy of Agasthiyar Kuzhambu with notchi leaf juice (Vitex nigundo L.) on the second day, and steam therapy was done with leaves of notchi for half an hour on admission day. The steam therapy relieved the excessive fluid accumulation around the ankles.
Agasthiyar kuzhambu (herbomineral Siddha formulation containing ingredients such as purified Mercury Quicksilver, Purified Sodium Chloride Impura, Sodium Biborate, Red Orpiment, and Trisulphite of Arsenic, and some herbal drugs) is one of the well-known Siddha classical preparations that has been used for varieties of diseases likesuram (hyperpyrexia), araiyaapu (bubo), kabhala vali (cephalgia), gunmam (gastralgia), kalladippu (renal calculi), 13 types of sanni (delirium), maladu(infertility), etc., with various adjuvants. The ingredients of this purgative drug possess antioxidant, anti-microbial, antiviral, antifungal, anticarcinogenic, anticancer, anticytotoxic, anthelmintic, antagonistic, antidiabetic, antispasmodic, antihypertensive, antispasmodic, antipyretic, antiinflammatory, anti-retroviral, analgesic, antinociceptive, hypolipidemic, relaxant, neuroprotective, bronchodilator, diuretic, immunomodulator, gastroprotective, hepatoprotective, nephroprotective, and anti-asthmatic properties (31). It is predominantly used with notchi leaf juice to normalize the deranged vatham (rheumatism, chronic pain) and to regularize digestion, which is helpful in the good absorption of the drug from the gut and is used in the management of the Naalavibatha punn . The second day of purgation therapy itself relieved the pain moderately. The third day of complete rest was advised to the patient to prepare the body and gut to receive the upcoming internal medicines effectively.
The ulcer was cleaned daily by the Padikara Neer, and dressing and bandaging were done by mathan thailam . Padikara neeris one of the external medicines that contain water and alum. It is commonly used for gargling, washing the wound, as eye drops for eye diseases, and to stop bleeding from the nose as nasal drops. It cures aphthous ulcers and other ulcers. Alum has the properties of wound healing, being anti-hemorrhagic and anti-microbial, which arrest the bleeding from the wound, support the removal of necrosed tissues by the formation of new tissues, and prevent the spread of ulcers by suppressing or avoiding the growth of the microorganisms (32).Mathan Thailam (Patchai Ennai ), which is one of the best wound healing medicated external oils, widely used by Ayush doctors, has anti-ulcerogenic properties with the ingredients Thurusu(purified copper sulfate), coconut oil (Coccus nucifera. L.) and leaf juice of Oomathai (Datura metel var. fastuosa.L. ). Thurusu and Oomathai have analgesic, anti-microbial, anti-fungal, and wound-healing properties that remove the debridements of the ulcer and support healthy cell proliferation around the ulcer (33). Coconut oil also supports the wound-healing process because of its bioactive components (34).
The internal medication Rasa gandhi mezhugu is mentioned in theSiddha Vaidhiya Thirattu to treat a variety of diseases, including cervical adenitis, scabies, alopecia, cancer of the penis, vaginal cancer, oral cancer, carbuncle, piles, fistula-in-ano, leprosy, absecesses, cysts, neuralgia, etc.(35). It acts as an immunomodulator, which helps in the nourishment of the tissues for cellular growth and removes the necrosed tissues.
By decreasing the inflammatory mediators, the adverse changes surrounding the ulcer were avoided. The combination ofParangipattai Chooranam, Sangu Parpam, and Silasathu Parpam— all three drugs have wound healing and bacteriostatic properties, so it is helpful in the healing of the ulcer by suppressing further infections of the ulcer and promoting the formation of healthy tissues.
Indications for leech therapy in the Siddha system of medicine areadipatta veekam (traumatic edema), puttru noi (tumourous growth), kattikal (abscess), idaividatha vaanthi(uncontrolled vomiting), thalaivvali (headache), vayiru and marbu noikal (abdominal and chest diseases), kalleral veekam(hepatomegaly), kakkuvan irumal (whooping cough), kann noikal (eye diseases), and mootu veekam (joint swelling) (21). The saliva of the leech contains numerous amounts of enzymes that promote the growth of healthy tissues, and the enzymes get mixed with the patient’s blood, which helps in the prevention of clot formation, which is the main complication of DVT in the long-term varicose vein.
After 60 days of follow-up, the patient insisted on consulting an angiologist at St. Thomas Hospital, Chethipuzha, Changanassery, Kerala, and the Doppler study for the right lower limb venous structure was taken to look for any DVT formation, and it revealed that there was no evidence of DVT and no abnormal venous valves were found. So the physician advised her to take the Siddha interventions, and there was no need for surgery. The patient was under follow-up for the next 8 months and was advised to take Parangipattai Chooranam , Palagarai Parpam, and Silasathu Parpam for the next 3 months after 60 days of treatment.
In the present case, Naalavibatha punn, the aggrieved primary dhosam is vatham (air + space), and the second is pitham(fire) and kabham (earth + water). These lines of intervention were followed to normalize the deranged uyirthathukal . After treatment, the VCS Score was reduced to 4 (mild), and the other symptoms like pain, itching, and swelling have reduced significantly. Dilated veins in the affected area shrank well. The hyperpigmented skin lesions were diminished markedly. Overall, the subject showed a significant improvement in subjective and objective parameters. During this case study, no adverse effect was noted. The internal medicines such as Rasa Gandhi Mezhugu, Parangipattai Chooranam, Silasathu Parapamand the external therapies padikara neer washing, mathan thylam topical application, and attai vidal showed a significant improvement in all the associated symptoms in the treatment ofNaalavibatha punn . The state of the ulcer in the patient and its improvement were noted and documented in Figure 3.
ConclusionBased on the clinical report, we may conclude that Attai vidal(Leech therapy) can give a ray of hope in the treatment ofNaalavibatha punn (Varicose ulcer) with internal and some other external therapies like wound cleaning with medicated Padikara neer and external oil application like Mathan thailam . None of the complications, like severe bleeding, wound infection, or hypersensitivity, were observed during the therapy. Leech therapy proves to be an effective, time-saving, affordable, and acceptable treatment. Though treating varicose ulcers is a difficult task, we have managed to treat them with “Leech Therapy” along with Siddha medicines. Additionally, further evaluation should be conducted with a large sample size to exhibit the efficacy of Siddha treatment for theNaalavipatha punn (Varicose ulcer).