Jalaukavacharana - Leech Therapy in Ayurveda

Leech Therapy in Ayurveda - A unique modality of treatment in Ayurveda - Insights into Scientific Aspects, Mode of Usage and its scope in treatment of Various Diseases.

1. JALAUKAVACHARANA & ITS DEVELOPMENTS IN THE MODERN SURGICAL ERA By , Dr. Adithya J V Assistant Professor JSS Ayurveda Medical College and Hospital Mysuru-08 1

2. Index 2

3. Importance of Jaloukavacharana 3

4. Historical Aspects of Jalauka 4

5. Sushruta Samhita , the oldest available manual on surgery has devoted an entire chapter for the description of Jalaukas in the chapter Jalaukavacharaniya adhyaya for the purpose of blood letting . Jalaukavacharana is claimed to be the supreme therapy because of its safety and high efficacy in the disorders involving the vitiation of blood. 5

6. They were used as a surgical agents to extract the blood of patients in a painless manner. For this reason, leeches were extensively used, in the past, in surgery for blood letting (Phlebotomy). From the time of early Greek medicine, there are records of leeches for blood letting. 6

7. Reference in Unani Medicine Unani medicine has also described the surgery – Ilaj-bil-Yad . In this, they had mentioned leeching as a Taleeq . According to them, leech application is a unique method for removal of toxic matter from the blood . It is useful in Slun diseases i.e. baldness and ring worm. 7

8. References made by Eminent Scholars Blood letting tools have been dated to the Stone Age . There is evidence of therapeutic bloodletting among Ancient Egyptians , Aztecs, Babylonians , although the first written record of the practice is found in the Corpus Hippocraticum . Avicenna , in his book “ Cannon of Medicine” , has described utility of leech therapy in various diseases. 8

9. Hirudo medicinalis , was commonly used for phlebotomy in Europe in olden times and the practice, at one time spoken as “ leechery ”, was so common that doctors themselves were often called “ Leeches ”. The medicinal leech of America is Macrobdella decoraso , so great was the demand for leeches for medicinal use that suitable species were even cultured in huge leech farms. Nachtrieb (1912) states that about in year 1850 , one American leech farm disposed of as many as 1000 or more leeches daily. About 7 million leeches were used in London hospitals and 5 to 6 million in Paris hospitals in 1863. 9

10. 10 Classification

11. JALAUKA - Definition 11

12. JALAUKA – ETYMOLOGY: जलमासामायुरिति जलायुका:, जलमासामॊकं इति जलौकस: ॥ सु.सू.१३/९ जलौकसस्तु सुखिनां रक्तस्रावाय योजयेत् ॥ अ.हृ.२६/३५ The word Jalauka is a compound word with two components Jala + Ayu ; The animals having water as the life. The term Jalauka can be split into Jala + Oka ; The water dwelling animals. 12

13. Shabdakalpadruma has considered Jalauka in feminine gender and defined it as an aquatic creature employed to expel out the vitiated blood. Bhagavadgomandalam defines Jalauka as an animal living either in water or in mud with distended abdomen. 13

14. SYNONYMS Jalayuka , Jalaua , Jaluka , Jalaluka , Jaalalauka , Jalita , Jaloka , Jalauga , Jalatani , Jalaukas , Jalasuchi , Jalaukasu , Jalasarpini , Raktapata , Ruktapa , Raktapayini , Vanini , Vedhini , Venika . 14

15. Jalauka Classification ता द्वादश: , तासां सविष षट् , तावत्य एव निर्विष ॥ सु.सू.१३/१० 15

16. SAVISHA JALAUKA The Savisha Jalauka originates in ponds of stagnant and turbid water containing the decomposed bodies of poisonous insects, toads and poisonous fishes . General characters of Savisha Jalauka : स्थूलमध्या: परिक्लिष्टा: प्रुथ्व्यो मन्दविचेष्टिता:। अग्राहिण्यो अल्पपाहिन्य: सविषाश्चा न पूजिता : ॥ (सु.सू.१८/१३) 16

17. तत्र सविष : - कृष्ण कर्बुर अलगर्दा इन्द्रायुधा सामुद्रिका गोचन्दना ॥ सु.सू.१३/११ Types of savisha jalauka 17

18. 1. KRISHNA: अन्जनचूर्णवर्णा पृथुशिर: कृष्णा: ॥ सु.सू.१३/११ 18

19. 2.KARBURA वर्मिमत्स्यवदायता चिन्नॊन्नत कुक्षि : कर्बुरा || सु.सू.१३/११ 19

20. 3.ALAGARDA रॊमशा महापार्श्वा कृष्णामुखि अलगर्दा || सु.सू.१३/११ 20

21. 4.INDRAYUDHA इन्द्रायुधवद् ऊर्ध्व राजिभिस्चित्र इन्न्द्रायुधा || सु.सू.१३/११ 21

22. 5.SAMUDRIKA ईषदसिपितिका विचित्रपुष्पाकृतिचित्र सामुद्रिक : || सु.सू.१३/११ 22

23. 6.GOCHANDANA गोवृषणवत् अधोभागे द्विधाभुताकृतिर् अणुमुखि गोचन्दन इति :॥ सु.सू.१३/११ 23

24. FEATURES OF SAVISHA JALAUKA BITE: श्व्यतु अतिमात्रं कण्डु मूर्च्छा ज्वर दाह छर्दि मदा सदन || सु.सू.१३/११ 24

25. NIRVISHA JALAUKA पद्मोत्पल नलिन कुमुद सौगन्धिक कुवलय पुन्डरीक शैवालकोथजात विमलेष्वम्भसः च निर्विष ॥ सु.सू.१३/११ Nirvisha Jalauka originates in decomposed vegetable matter, as the putrified stems of the several aquatic plants known as Padma , Utpala , Nalina , Kumuda , Pundarika and common zoophytes, which live in clear water. 25

26. General characters of Nirvisha Jalauka : महाशिर बलवत्यः शीघ्रपायिन्योः महाशन ॥ सु.सू.१३/१३ अथ निर्विषा : कपिला – पिन्गल - शंखमुखि – मूषिका – पुन्डरिकमुखि – सावरिका । सु.सू.१३/१२ 26

27. 1.KAPILA मन:शीलारन्जितः पार्श्वाभ्यां प्रुष्टे स्निग्धा मुद्ग वर्णाः । सु.सू.१३/१२ 27

28. 2.PINGALA रक्ता व्रुत्त्काया आशुगा: ॥ सु.सू.१३/१२ 28 Mimobdella buettikoferi

29. 3.SHANKAMUKHI यक्रुद्वर्णा शीघ्रपायिन्योः दीर्घतीक्ष्णमुखी । सु.सू.१३/१२ 29

30. 4.MUSHIKA मूषिकाक्रुतिवर्णाः अनिष्ट गन्धाः । सु.सू.१३/१२ 30

31. 5.PUNDIRAKAMUKI मुद्गवर्णाः तुल्यवक्त्र पुन्डरीकमुखीः । सु.सू.१३/१२ 31

32. 6.SAAVARIKA स्निग्ध पद्मापत्रवर्णा अष्टादश अन्गुल प्रमाणा । सु.सू.१३/१२ 32 Giant Amazon Leech Worlds biggest species of leech

33. 33

34. HABITAT AND COLLECTION OF LEECHES Habitat of leech Methods of collection Time of collection Preservation of leeches after collection 34

35. Habitat of Non Poisonous leeches तासां यवन पान्ड्या सह्या पौथनादीनि क्षेत्राणि । सु.सू.१३/१२ 35

36. Method of collection of leeches Acharya Sushruta , has told that the leeches can be caught with a piece of wet leather - in tanks, streams and water bodies where there are lotus. There is another method to collect the leeches i.e. the fresh meat of dead animals, fish or milk must be applied on the thigh of an animal or the human himself, then tie it around his thigh ( Jangha ) and immerse tied part i.e. the Jangha in the water for some time. Due to attraction towards these diet, Jalauka will come and start biting. Then they are made to leave dead meat/skin with the application of Saindhava lavana (rock salt) and collected. 36

37. 37

38. Time of Collection Sharad Ritu (Autumn) OCTOBER TO NOVEMBER 38

39. Preservation of leeches It is put into a large sized new pitcher filled with water and slime of the pool. Shaivala and powder of dried meat and aquatic bulbs should be put into the pitcher for feeding. Blades of grass and leaves of aquatic plants should be put into it for them to lie upon The water and edibles should be changed every two or three days The pitcher should be changed every one week. 39

40. 40

41. तत्र वात पित्त कफ दु ष्टशॊणित यथा संख्यां श्रुंग जलौकालबुभिर् अवसेचयेत् ॥ Su.Su.13/4 Blood vitiated by Vata – Pitta – Kapha should be let out by means of Shrunga – Jalauka – Alaabu respectively. शीताधिवासा मधुरा जलौक वारिसंभवा । तस्मात् पित्तोप्सृष्टे तु हिता सा त्ववसेचने ॥ Su.Su.13/6 Leech emerges from water , Lives in Cold climate and is sweet and as such is useful in blood letting in those diseases vitiated by Pitta . 41

42. PARAMA-SUKUMARO-AYAM नृप आड्य बाल स्थविर भीरु दुर्बल नारी सुकुमाराणाम् अनुग्रहार्थम् परमसुकुमारो अयं शोणितावसेचन उपायो अभिहितो जलौकसः ॥ सु.सू.१३/३ Application of leech is the most delicate method of blood letting prescribed particularly for the benefit of Kings Wealthy persons Children Timid Debilitated Women Most Delicate persons 42

43. INDICATIONS FOR JALAUKAVACHARANA 43 गुल्मा अर्शस्

44. 44 वात रक्त कुष्ट दुष्टा व्रणा

45. 45 श्वयतु स्किन् ग्राफ़्ट्

46. 46 चर्म रोगा चर्मा रोगा

47. 47

48. 48

49. PURVA – PRADHANA – PASCHATH KARMA Classical method of application of leech 49

50. PURVA KARMA Patient : 1 . Examination of the patient who is fit for Jalaukavacharana . 2 . Preparation of the patient: Snehana and Swedana Karma is to be instituted to the affected site where leech will be applied . The affected part is to be rubbed ( Vigharshan ) by the rough powder of mrt or gomaya churna . It is contraindicated if the part is ulcerated. Jalauka : Selection of the leech Activation of the leech Before the application of leech, it should be kept in the Haridra mixed water till they become active and then cleaned with the help of pure water. 50

51. ACTIVATION OF LEECH Acc. To Acharya Sushrutha : ग्रहिताश्च सर्षप-रजनीकल्कॊदक प्रदिग्ध गात्रे: सलिलसरकमध्ये मुहूर्त स्थिता विगतक्लमा ज्नात्व ताभिं रोगं ग्राहयेत् ॥ सु.सू.१३/१९ Acc. To Acharya Vagbhatta : Suitable jalauka must be selected and kept in water containing निशा कल्क , सोम (water in which grains are washed) or तक्र and it should be made comfotable by putting back in pure water 51

52. 52

53. SCIENTIFIC REASON BEHIND THE ACTIVATION OF LEECH The digestive tract of the medicinal leeches has been found out to contain two types of Bacteria’s namely : * Aeromonas Veronii ; * Aeromonas Rikenella ; * Aeromonas Hydrophilla ; If these enters into the blood circulation , it may cause wound infections . 53

54. 54

55. PRADHANA KARMA The patient must be prepared as stated above. The leech will be too much unctuous and soft and as a result it slips off from the hand. It is better to catch leech either with the gauze or after wearing the rubber gloves. Then the leeches should be taken out of their receptacles and put over the selected place. Leeches attach to the skin by two muscular suckers before biting with three jaws inside their anterior suckers and takes the shape of horse shoe shape i.e 55

56. * अश्वखुरवदानानं * उन्नम्य च स्कन्धं The leeches having stuck to the affected part may be inferred from the mouths of the leeches assuming the shape of horseshoe and raised and arched position of their necks after they had attached to the seat of the disease. 56 यदा च निविशते अश्वखुरवदानानं क्रुथ्वे उन्नम्य च स्कन्धं तदाः जानीयाद्ग्रुह्णातीति: ||

57. 57

58. If the leech doesn’t bite the desired part: अग्रह्णान्त्यॆ क्षीर बिन्दु शोणीत बिन्दु वा दध्यात् शस्त्रपदानि वा कुर्वीत: यध्येवमपि न ग्रह्णियात्त तदाअन्यां ग्राहयेत् ॥ सु.सू.१३/१९ After leech starts sucking the blood , ग्रह्णान्ति चार्द्रवस्रावच्छ्न्नं क्रुत्व धारयेत् ॥ सु.सू.१३/१९ 58

59. Indicating signs for removing leech दंशे तोद कण्डु प्रादुर्भावै जानीयात् च शुद्द्मियष्मदत्त् इति: शुद्दमानामपनयेत् || सु.सू.१३/ A sensation of itching at the seat of application. (क्ण्डु प्रादुर्भाव) A drawing pain at the seat of application. (तोद) 59

60. जलौकास्त्वात्म प्रभावेण प्राग्दुष्टेमेव रक्तं पिबन्ति । यथा दुग्धमिश्रित उदकां हंसो दुग्ध्मेव पिबतीत्यर्थः॥ अ.ह्रु.सू २६/४२ 60 Prabhava

61. Directions to remove the leech: अथ: शॊणित गन्धेन न मुन्चेत् मुखाम् आस्या: सैन्धव चूर्णेनावकिरेत ॥ सु.सू.१३/३४ Sometimes leeches refuse to fall even after the appearance of the desired signs, due to their fondness for the smell of blood. They should be sprinkled with the dust of powdered Saindhava ( Sushruta ) or Haridra churna ( Vagbhatta ) upon their mouth. 61

62. PASCHATH KARMA 62

63. 1. Care of the patient Samyak yoga शॊणितस्य योगा-अयॊगान् वक्ष्य शतधौतघ्र्ताभ्यन्ग: तत्पिचुधारणं वा:॥ As soon as the leech is removed from the body an application with Shatadhauta Ghrita should be applied on the wound; or Pichu dipped in Shatadhauta Ghrita should be kept on it. Heena Yoga जलौकव्रणान् मधुना अवघट्ट्येत् शीताभिरद्भि॥ Ati Yoga परिषेचयेत् भध्नीयात् वा कषाय-मधुर-स्निग्ध शीतैस्च प्रदेहै: । Asamyak Yoga 63

64. 2.Care of the leech : अथ पतितां तन्डुल कन्डन प्रदिग्धगात्रीं तैल लवणाभ्युक्तमुखिं वामहस्त अन्गुष्ट अन्गुलिब्यां ग्रहीत पुच्छा दक्षिणहस्तांगुष्टान्गुलिभ्यां शनैः शनेर्-अनुलोमम् अनुमार्जयेत् मुखात् वामयेत् तावध्यावत् सम्य्क वान्तालिन्गानिति॥ सु.सू.१३/३५ After falling of, the leech body should be anointed with तन्डुल् and mouth should be massaged with oil and salt. Then they should be caught by the tail end with the thumb and the forefinger of the left hand and their backs should be gently rubbed with the same fingers of the right hand from tail upward to the mouth with a view to make them eject the full quantity of blood. Then leeches should be kept in a separate pot containing pure water. 64

65. 65

66. Samyak Vantha Lakshana /Finding of proper vomitting सम्यग्वान्ता सलिलसरके न्यस्ता भोक्तु कामा सती चरेत॥ सु.सू.१३/२४ अथं सुवान्ता पूर्ववत् सन्निदध्यात् ॥ सु.सू.१३/२७ Leeches that had vomited the full quantity of blood sucked would move very actively in quest of food when placed in water on the contrary if there is no complete vomiting of blood they would be lying dull and inactive. 66

67. Durvantha Lakshana :- या सीदती न चेष्टते सा दुर्वान्ता, तां पुना: सम्यग् वामयेत॥ सु.सू.१३/२९ दुर्वान्त्या व्याधिर साध्या इन्द्रमदो नाम भवति । सु.सू.१३/३० It gives rise to an incurable disease particularly known as Indramada means Raktamada or Raktamatta . 67

68. Modern aspect of Sophisticated Blood Sucker :Leech 68

69. Anatomy and Physiology of the leech 69

70. 70

71. Basically there are around 650 species of leeches found all over the world. Medicinal leeches commonly used is the Hirudo medicinalis or the European Medical Leech. Other species sometimes referred to as Medical Leeches include (but are not limited to): 71

72. HIRUDINARIA The genus Hirudinaria comprises fresh water leeches, which are sanguivorus (Blood sucking) in habit and attack domestic animals and man. Four species of these are found in India, namely H. javanica , H. manillensis , H . granulosa and H. viridis occurring in the ponds and ditches. The account given here refers to Hirudinaria granulosa . 72

73. FEATURES OF H.GRANULOSA 73

74. H.Granulosa on maturity measures about twelve inches in length. It is greatly elongated , appears more or less cylindrical in a state of contraction, but is found to be dorso -ventrally flattened in stretched condition. The dorsal surface is more or less plane, transverse section of the body, is elliptical in shape. The dorsal surface is green and ventral orange. The external surface of the body is segmented into about one hundred rings or annuli by a series of well-marked grooves, which are striking enough in natural condition. 74

75. These organisms have two suckers, one at each end, called the anterior  and posterior suckers . The posterior is used mainly for leverage, whereas the anterior sucker, consisting of the  jaw and teeth , is where the feeding takes place. Medicinal leeches have three jaws (tripartite) that look like little saws and on them are about 100 sharp teeth used to incise the host. Large adults can consume up to ten times their body weight in a single meal, with 5-15 ml being the average volume taken.  These leeches can live for up to a year between feeding Medicinal leeches are   hermophrodites that reproduce by sexual mating, laying eggs in clutches of up to 50 near water and in shaded, humid places. After birth leeches can live up to 19 or 30 years. 75

76. 76

77. Leech Eggs 77

78. SENSES AND MOBILITY Medicinal leeches have 5 pairs of eyes , but they do not see the full spectrum of a picture, although leeches can find their way almost perfectly. Smell, taste and touch are well-developed , which help leeches to survive. It is worth noticing that leeches wonderfully respond to smell of items that are deep down the water. Few researches tell a leech has 32 brains !!! Anterior and Posterior Brain with 21 segmental ganglions in turn branching into about 175 sensory neurons from each ganglion . 78

79. 79

80. 80

81. Enzymes and chemicals secreted by leech 81

82. Sl.No Enzymes/Chemicals Action 01 Hirudin R estrains the clotting of the blood, works as diuretic and an antibiotic. It keeps the wound open for the approx. 30 minutes after sucking act and keeps the blood fluid. 02 Calin R estrains the blood clotting. 03 Hyaluronidase is a spreading factor that ensures that the other active substances which are effective at the bitten areas can spread. 04 • Eglins R estrains digestive proteases. 05 Bdellin These substances have antiphlogistic , antibiotic and further characteristics. 06 Destabilase D issolves Fibrin and has thrombolytic effects 07 Eglins Factor XA Inhibitor I nhibits the activity of coagulation factor XA 08 Compliment Inhibitors R eplace natural compliment inhibitors if they are deficient 09 Carboxy peptidase A inhibitors I ncreases the inflow of blood 10 Acetyl Choline V asodialotor 11 Anaesthetic Like Substances R educes pain during the biting of leech 82

83. Mode of Action 83

84. A medicinal leech is a small factory to manufacture biologically active substances which has following actions Normalization and improvement of capillary circulation. Vaso dialator Corrects venous hypertension Anticoagulation effect. Anti-inflammatory effect. Blood purification effect by expelling out the vitiated blood. Improvement of an endocellular exchange. Early wound healing effect. Local Anesthetic effect. Anti-bacterial effect. 84

85. Mode of action in Infected Wounds 85

86. Mode of action in TAO In case of TAO, where the arterial insufficiency is the main cause for discoloration of wound site. Hirudin and Hyaluronidase , breaks down hyaluronic acid. 86

87. Mode of action in Varicose veins & Ulcers Venous decongestion Reversal of edema Hyper pigmentation reduces Healing of varicose ulcer 87

88. Mode of action in inflammations 88

89. Mode of action in skin grafting/ microvascular surgeries Failure of adequate venous return from a graft reduces blood supply, causing tissue necrosis. Placing a leech on the congested skin flap, finger or compromised area removes the congested blood and enables the graft to be salvaged. Leeches are currently used during post-operative care of reimplanted fingers, skin grafts and breast reconstructions. Fresh leeches are applied as required for several days or weeks until the venous congestion is relieved and normal venous drainage of the graft has had time to develop. 89

90. 90

91. 91

92. 92

93. 93

94. Complications The histamine emitted by the leech can lead to an allergic reaction , which may immediately occur, or within four days. • A soreness after the bite rarely appears. • A small scar at the bitten area may remain for weeks. •A plaster allergy is more often found after a treatment with leeches, therefore it is advisable to use skin preserving, hypoallergenic plasters. 94

95. RESEARCH BREAKTHROUGHS IN THE FIELD OF LEECH Chemical Advancements Mechanical Leech Certified Leech therapists Leech Oil in Cosmetics 95

96. FDA Approval of leech therapy Two Slovenian surgeons, M. Derganc and F. Zdravic who published a paper in the British Journal of Plastic Surgery in 1960 describing leech-assisted tissue flap surgery (in which a flap of skin is freed or rotated from an adjacent body area to cover a defect or injury). That paper and many other studies had helped put leech therapy in the list of approved and classified medical devices in the very early of the 21 st century, the year of 2004. The French made it again by having the first approval for the marketing of medicinal leeches in North America . 2004 was really the greatest year for the surgeons and other physicians who have worked with leeches in micro and constructive surgery. That was the year the FDA approved the request of the French company, Ricarimpex , for the commercialization of medicinal leeches in the United States. This approval of medicinal leeches as a medical device in the field of plastic and reconstructive surgery has helped LEECH USA to do the commercialization of the medicinal leeches in United States for the French company . Leech USA has been selling medicinal leeches since 1986. 96

97. Hirudin (and related substances) are synthesised using  recombinant techniques called as BIVALIRUDIN. Devices called “ Mechanical leeches " that dispense hirudin and perform the same function as medicinal leeches have been developed, but they are not yet commercially available. 97

98. Mechanical Leech A device invented to augment blood removal after passive bleeding 98

99. Working of the mechanical leech 99

100. Uses of Mechanical Leech Used to relieve venous congestion Prevents pooling of blood Increases tissue perforation and thus maintains viability of the tissue until neovascularisation occurs. 100

101. BIVALIRUDIN Semi synthetic derivative of hirudin . 101

102. Uses of Bivalirudin 102

103. Advantages over heparin 103

104. Leech use in Cosmetics As for the advantages of the leech saliva, it improves blood microcirculation and supplies oxygen to the tissues, stimulates the local immune system, antioxidant activity, eliminates pigmentation disorder, protects the skin from environment, slows down aging, makes the skin more elastic and keeps moisture. 104

105. Leech extract 105

106. 106

107. 107

108. 108

109. 109

110. 110

111. 111

112. 112

113. 113

114. 114

115. 115

116. DISCUSSION Indications of leech told by Sushrutha holds good till today as it can be safely applied in all ages and variety of raktha pradoshaja vyadhies . Many people fear or faint just by the sight of blood. Hence, it is visually appealing as the blood let out by the leech wont be visible to the patients making them comfortable. They are very effective in treating very grave prognosed cases like diabetic foot , DVT, Gangrene etc where it’s a limb saving as well as life saving treatment. 116

117. Its very cost effective treatment modality Its easily available Its a painless procedure in contrast to surgical techniques used for blood letting. Can take up leech therapy as a profession Can take up leech farming as it is a very lucrative business 117

118. CONCLUSION क्षेत्राणि ग्रहणं जाति: पोषण सावचारणं ॥ जलौकसां च यो वत्ति तत्साध्यान स जयेत गदा ॥ “The clinician who knows all about the leeches, habitat, their method of collection, varieties, storage and method of application is successful in treating the diseases amenable to them” – [ Sushruta Su. 13/24]. 118

119. e-References http://www.irjponline.com/admin/php/uploads/1247_pdf.pdf http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3296343/ http://www.ncbi.nlm.nih.gov/pubmed/22736888 http://interscience.org.uk/v2-i2/17%20ijahm.pdf https://www.researchgate.net/signup.SignUpFinished.html\ https://www.google.co.in/search?q=jalaukavacharana+ppt&oq=jalaukavachara&aqs=chrome.0.69i59l2j69i57.998358j0j8&sourceid=chrome&es_sm=122&ie=UTF-8

120. Points of Interest for discussion After how many days a same leech can be re-applied ? रक्षन् रक्तमदाद्भ्य: सप्ताह्ं ता न पातयेत् ॥ अ.ह्रु.सू २६:४४ What’s the maximum number of leeches that can be applied at a single time ? What’s the quantity of blood that a leech sucks at a single time ? Does it act as a vector to transmit any blood borne diseases ? M. Nehili , C. Ilk, H. Mehlhorn , K. Ruhnau , W. Dick, & M. Njayou ; Ilk; Mehlhorn ; Ruhnau ; Dick; Njayou (1994). " Experiments on the possible role of leeches as vectors of animal and human pathogens: a light and electron microscopy study". Parasitology Research . 80 (4): 277–90. doi : 10.1007/BF02351867 . PMID   8073013 .   120

121. 121

122. 122 Thank you