|Year : 2022 | Volume
| Issue : 1 | Page : 19-26
Critical review to understand the twenty-four Ayurveda treatment modalities for the management of snake bite
Narayan Pandey1, Anita Sharma1, Vd. Amol Kadu1, Shankar Gautam2
1 P.G. Department of Agad Tantra, National Institute of Ayurveda, Jaipur, Rajasthan, India
2 Department of Kayachikitsa, National Institute of Ayurveda, Jaipur, Rajasthan, India
|Date of Submission||30-Sep-2021|
|Date of Decision||03-Feb-2022|
|Date of Acceptance||08-Feb-2022|
|Date of Web Publication||31-Mar-2022|
Dr. Narayan Pandey
P.G. Department of Agad Tantra, National Institute of Ayurveda, Amer Road, Jaipur 302002, Rajasthan.
Source of Support: None, Conflict of Interest: None
Background: Snakebite is a major problem worldwide, and a common medical emergency. There are many treatment modalities available for snake bites, among them Chaturvimsati Vishachikitsopakrama are Ayurveda treatment modality mentioned in Charaka Samhita. The concept and procedures of few Upakramashas also been clearly defined in other Samhitas like Sushruta, Astangasamgraha, Astangahrdaya. Aims and Objectives: To understand the role of Chaturvimsati Vishachikitsopakramain the management of snake bite with the help of Bruhatravi, Laghutrayi and contemporary scienceMaterials and Methods: The keywords such as snake, snake bite, Chaturvimsati Vishachikitsopakrama, management of snakebite were searched from literary of classical text books like CharakaSamhita, SushrutaSamhita, Astanga Hridaya, etc with its responsive commentators, various databases (PubMed, Google scholar, Research gate, Ayush Dhara). Results: There are few traditional healers who are practicing some of the treatment modality of Vishochikitsopakram such as Mantra, Arista, Aaushad etc. Same procedure has been advocated in contemporary science with different terminology. In other hand few treatment modalities mentioned to avoid in snake bite management such as Utkartan, Chushan etc. Conclusion: Among the classical 24 treatment modalities, few are scientifically validated whereas few need to be studied and some are found irrelevant in the current scenario. Many Upakramas are scientifically approachable, easily accessible, cost effective, time saving and can be performed anywhere. So, these treatment modalities should be researched and implemented with the advancement of this era.
Keywords: Antidote, anti-venom, snake, snake bite, snake venom, Upakrama, Vishopakrama
|How to cite this article:|
Pandey N, Sharma A, Kadu VA, Gautam S. Critical review to understand the twenty-four Ayurveda treatment modalities for the management of snake bite. J Indian Sys Medicine 2022;10:19-26
|How to cite this URL:|
Pandey N, Sharma A, Kadu VA, Gautam S. Critical review to understand the twenty-four Ayurveda treatment modalities for the management of snake bite. J Indian Sys Medicine [serial online] 2022 [cited 2022 May 27];10:19-26. Available from: https://www.joinsysmed.com/text.asp?2022/10/1/19/342313
| Overview (Introduction)|| |
Ayurveda has Eight Aanga, among them Agad Tantra is one. Agad Tantra deals with the detailed study about poisonous sign and symptoms that produced by the bite of snake, insects, scorpions, rat etc., identification, detection and the management of natural, artificial and combined poison. Among them the poison/venom produced from snake bites has been discussed here. In worldwide especially in south and southeast Asia, Africa, Latin America, Snakebite is becoming the cause of morbidity and mortality. Because of the variation in climate, different kinds of poisonous as well as non-poisonous snakes have frequently been reported. India is one of the most common countries where cases of snakebite have frequently been found, which becomes an emergency. The dense and dark forest of India offers the best habitat for the reptiles, the jungle offers a wide range of areas for snakes to the giant with abundant prey. There are near about 270 plus species of snakes in India, among them, nearly 60 are highly venomous. The big dangerous snakes of India include Indian cobra, krait, Russel, Viper, and saw-scaled viper. Every year in India, almost 20000 people die because of venomous snake bites. In India Saw scale viper and Russel’s viper species have frequently encountered. In the Maharashtra state of India, the annual incidence of severe envenomation is about 70 per 100000 inhabitants and the mortality rate is about 2.4 per100000 per year. All such types of species shown 100% fatality if there is no use of Anti-snake venom (ASV) for the treatment of snakebite. In an ancient period, there were cases of snakebite, traditional healers used traditional medicine (Ayurveda management) and they were cured. But with the advancement of time and development of modern medicine, the classical procedures are not frequently being in practice. They commonly use Anti-snake venom from modern science. For treatment of poisonous snake bites, the area should be highly facilitated with advanced equipment so this process cannot perform in very rural villages. Anti-snake venom is itself venom (poison), it is used on the patient only after showing poisonous signs and symptoms of snakebite, otherwise anti-snake venom may cause death if it is used in non -venomous snake bite. Anti-snake venom after infusion may produce anaphylactic reactions (rashes, itching sensation especially on feet or hands, redness of skin, mostly around ear, swelling of face, eyes or inside of nose, difficulty in breathing and swallowing, unusual weakness and tiredness), serum sickness (enlargement of lymph node, generalized itching and rashes, inflammation of joints, fever), pyogenic reactions. And serum sickness (Delayed antivenom reaction) with clinical symptoms like fever, lymphadenopathy, arthralgia, a cutaneous eruption which is mostly seen after 8-10 days of antivenom infusion.,
Ayurveda has mentioned Caturvinshanti Vishachikitsopakrama for the treatment of insect bites including the snake. Those Upakrama have been used from thousands of years ago. Without any complications, we can perform everywhere even in the lack of advanced instruments. So, the importance of the Ayurveda line of treatment in the case of snake bites has been emphasized through this review article.
Aims and objectives:
to understand the role of Chaturvimsati Vishachikitsopakrama in the management of snake bite with the help of Bruhatravi, Laghutrayi and contemporary science
| Materials and Methods|| |
The keywords that have been searched are snake, snake bite, Caturvinshanti Vishachikitsopakrama, management of snakebite. These have been searched from literary of classical text books like CharakaSamhita, SushrutaSamhita, Astanga Hridaya, etc with its responsive commentators, Multiple database (PubMed, Google scholar, research gate, AyushDhara). Many of the textbooks of modern medical sciences and peer-reviewed medical Journal has been reviewed as a keyword
| Classification of the Snake|| |
According to Ayurveda
In Astangasangraha of Vagbhat, snake has been classified into two groups i.e., Divya and Bhaum, Vasuki,Takshaketc. are the example of Divya snake.Sushruta has further subclassified BhaumSnakes into five groups they are:Darvikar, Mandali, Rajiman, Nirvisha and Vaikaranja.
According to Modern
Most of the snakes have been classified into two main groups:
- (A) Venomous
- (B) Non-venomous
Poisonous snake has been further classified into three types [Table 1]:
Categories of Snake Bites
Sushruta has been classified the type of snake bite into three groups [Table 2]:
|Table 2: classification of snake bite with their characteristics of bite according to Sushruta Samhita|
Click here to view
According to the effect of poison, Snake has been classified into two groups i.e., Savisha and Nirvisha. From contemporary point of view, snake has classified into two groups:
Dry Bites (type 1): It occurs when a snake does not release any venom with its bite. Mostly non-venomous snakes are included in dry bites.
Wet bites/venomous bites (type2): These are much more dangerous. Poisonous snakes voluntarily emit venom when they bite.
General Symptoms of Snakebite (Sarpadansha Lakshana)
Common symptoms of a poisonous snake bite are swelling with pain sensation on bite site along with pricking pain, having mass like eruption with itching sensation and burning sensation. and snake bite having none of these above symptoms comes under non-poisonous snake bite.
Management of Snake Bite Envenomation (Sarpadansha Chikitsa)
From allopathic science, the treatment line for poisonous snake bites is only through the Anti-venom snake (ASV), but the antivenom has its own moderate to severe life-threatening manifestations like anaphylactic reactions such as, difficulty in breathing, swelling of face, pyrogenic reaction, joint inflammation, enlargement of lymph node will be seen and finally may lead to death. Anti-venom only neutralizes the poison but not main for the elimination of the poison, and till remains in the body, so that part of poison which is not completely neutralize may harm to the body. That’s why the purificatory procedure which is mentioned in context of CaturvimsatiVishchikitsopakrama [Table 3] that will be helpful. Even in post bite complications, that can be easily eliminate through these Upakramas like Lepa, Raktamokshana, Pratisharan,Avagahan etc. that’s why it is the need for implementation of CaturvimsatiVishchikitsopakrama in different poisoning condition including snake bite.
Mantra is the Holistic word quoted in Rhythmic manner, from which one gets eternal power. It is assumed that repeated chanting (Mantra), earlier eliminate the poison from the system than medicines. In Classical text, specific kinds of Mantra has mentioned for specific poison. A truthful, ascetic, seer’s person when he/she uses Mantra by producing voice, such Mantra nullifies all kinds of poison even in dangerous poison. Such types of Mantras produced by brilliant, seers, destroy the poison of snake as much faster as medicine and described the methodology of Mantrakarma. Where in Kalpasthan of SushrutaSamhita mentioned for Mantra along with Arista Bandana (Rajju), that prevents the flow of poison.
All the proper measures should be taken within 100 Matrakala, because venom will be stay at bite site till that time, then it will spread to the whole body through circulation. Before spreading of poison,Venika (Rope or torniquet like)should be applied just above the bite site, and then forcefully squeezed to bite site.Arista-bandhan is more effective when applied with chanting but ligation should be neither too tight nor too loose because complications like swelling, necrosis will be seen, when ligation is too tight. The speed of flow of venom will stop like dam(Bandh) obstructs the flow of water. Sushruta emphasized to apply it about four inch above the bite site, made from either bark of plant or anything soft things. In contemporary science, ligation is prohibited but some study shows best intervention method to prevent from spreading of venom, into the systemic circulation by constricting the lymphatic vessels, blood vessels where they used Torniquet or any pressure immobilization bandage as ligation.
Utkartana, Nishpidana and Chushana
As the root cutting trees stops its growing up, like the same way, Doing Utkartan (incision) at bite site prevents from further spreading of venom. After incision, suggested for Achushana (sucking) of venom with proper care, which helps to flow out of venom containing blood. In Allopathic science, they avoid incision, because it can lead difficult in diagnosing the type of snake bite and also brings further complication. Similarly, Nishpidana (Squeezing) should performed from all around the bite site, that is usually applied on vital points or Joint area, where ligation cannot apply. After incision, Chushan(sucking) Karma is applied to eliminate venomous blood out, where mouth should fill with clothes or clay, ash, Agad or stool of cow or coating of mouth with oil, Ghee during Chushana Karma.
Application of Agnikarma (cauterisation) will destroy poison, that is situated in skin and muscle layer. This procedure can apply in all kinds of snake bite except Mandali. For this, specific type of Shalaka (sticks) made from either gold or iron should be used, that destroys all kinds of venom except venom of Mandali snake.
From contemporary view of literature this process is known as Cauterization. For this, hot coals, branding irons, Gun powder cigars, and even acid-born the affected site and take the venom out.
Parisheka, and Avagaha
When Visha enters into the body then advised for Parisheka (cold therapies) around the bite site with the extraction of herbs having cooling effect till horripilation, which arrest the spreading of poison by coagulation, also alleviates from further complications like fainting, toxicity, increased heart rate etc.,
Sushruta has advised for the application of Lepa (paste) formed with different kinds of herbs around the bite site and Parisheka (irrigate) this site with the water mixed with Chandan and Khas. In contemporary Science, it is one of the important means that prevents from spreading of infection by the process of Washing or irrigation with clean water, isotonic solution or antiseptic agent, around the bite site. Similarly, Avagahan (sudation by sitting in tub) is the process of immersion or dipping of the affected part into the medicated decoction or lukewarm oil. Here the bite site is dropped(sink) into the decoction made from different herbs having Vishaghna properties.
From contemporary view, this process can be compared with Hot water immersion (HWI). This procedure is generally applied for marine and freshwater envenomation, that helps to inactivate the venom component in some amount. Even, it will reduce inflammation by inactivating inflammatory receptors and improve metabolic health.
Raktamokshan and Pratisaran
Sushruta advised for Raktavishravan (bloodletting), when the body afflicted by poison with symptoms like discoloured, hard, swollen and painful. and the same is recommended for the first stage of Rajiman, Mandali and DarvikarVishaVega. And even mentioned to avoid Siravyadhnan (venepuncture) for pregnant woman, child, and old man. Vagbhat said that venepuncture is the excellent method of treatment to eliminate toxic blood.
Charaka advised for bloodletting with Prachhana (scratching with the help of rough instruments), Shringa (Horn), Sira-Vyadhana or leech therapy for bloodletting or direct by venepuncture and advised to let rubbing with the mixture of medicated powder like Trikatu, Haridra around the bite site when no blood is coming out even after these processes that helps to promote the bloodletting and this process is known as Pratisaran (rubbing). And application of cooling paste like paste of Vata, when excessive blood come out.
Sushruta mentioned seven kinds of VishaVega and advised to do Vamanakarma at the second stage of Rajiman Visha Vega followed by anti-poisonous recipes. Similarly, in fourth stage of Darvikar, Mandali and Rajiman Visha Vega advised for Vamana Karma. Again, advised to do strong Vamanakarma, when the person has bitten by snake with Kapha predominant and bitten in winter season with the features of salivation, fainting and intoxication.AcharyaVagbhat in Astanga samgraha advocated for Vamana Karma when the snake bite is above the umbilicus and through different kinds of procedures that increases and accumulates Kapha in the heart, that develops Heaviness, salivation and nausea, hence that patient should be induced vomiting by using emetic drugs.
Sushruta recommended for Virechana Karma in the third and fifth stage of MandaliVega, fifth and sixth stage of DarvikarVega, fifth stage of RajimanVishaVega.The person having Vata-Pitta prakriti with Pitta predominant, bitten by snake with PittaDosha predominant with features of burning sensation, pain, flatulence, obstruction of urine, stool and flatus, should be made to drink with purgative drugs. Similarly, Vagbhat mentioned for Vierchana Karma when a person with Pitta constitution has bitten by Snake of Pitta predominancy below the umbilicus, by using different kinds of purgative drugs.
When the vitiated Kapha obstructs the channels because of the effect of venom and interferes the normal movement of Vayu,and the patient will show features of going to die like deep inhale and expire, in such case advised for Kaakpad(incision) on scalp and apply the Mamsa of goat, buffalo, hen inside the incised wound, which helps to draw the poison from Rakta.Sushruta in his Kalpasthan of fifth chapter, has indicated this procedure in seventh stage of Darvikar Visha Vega.
Vagbhat also mentioned for application of pieces of fresh bloody Mamsa or skin over the incised (Kaakpad) region.
When a person has bitten by poisonous snake or any insects, at that case, primary aim is to protect heart by taking different medicines. For this purpose, honey, cow’s ghee, cow’s milk, Majja (bone marrow), juice of sugarcane, blood of goat etc., should give him immediately for protecting heart, that makes Avarana (covering) of heart. Poison mostly having TikshnaGuna, that weakens the heart, so in order to protect it, the patient should be made to drink pure ghee, ghee mixed with honey or anti-poisonous drugs added with more ghee and then advised for Vamana Karma.
Anjana, Nasya, Dhuma
Charaka recommended for Anjana and Nasya in fifth stage of VishaVega with the features like obstruction in the normal function of eye due to effect of venom, obstruction to the normal function of nose, ear, tongue and neck.Sushruta advised for Anjana and Nasya karma in third and seventh stage of Darvikar, Anjana in sixth and Nasya in seventh stage of Rajiman Vega and seventh stage forMandali. and again advised for Anjanakarma, when a person having features of swelling around the orbit of eye, with sleepiness, colourless of eye or visible of different colours, headache, heaviness, locked jaw or torticollis. In Uttartantra of 36th Chapter of Ashtanga Hridaya, Vagbhat recommended the application of Anjana and Nasyakarma formed by Agad of Tikshna herbs, when venom enters into seventh Vega.Dhuma refers to antitoxic medicated smoke that helps for the elimination of impure Kapha and clears the blocked channels, from which respiratory process gets stablished.
In a pilot study done on mice, it was found that the intranasal (IN) administration of neostigmine is effective and decreases the fatalities rate of victim by preventing from paralysis of brain and paralysis of respiratory muscles, thus saving the life that is caused by neurotoxic snake bite envenomation.
When mouth becomes dry due to Ruksha,Ushna properties of poison, then linctus mixing of ghee and honey is given to counteract of such properties of poison. In case of snake bite envenomation, generally dryness of throat and mouth occurs so advised to give medicine mixed with honey and Ghee that helps to pacify properties of poison.
Aushadha is broad term where, many internal and external medicines like Kashaya, Leha, Gutika, Nasya, Anjana etc. comes under this topic. Similarly, in classical text of Ayurveda, some specific kinds of Agada or Yoga have mentioned, which are indicated for specific types of snake bite envenomation [Table 4].
In kaphaj predominant snake bite, after main treatment i.e., Vamanakarma, patient is advised to take Kashaya, Katu, Tikta Rasa dominant Aahara. Similarly, in Pittaj predominant snake bite, patient is advised to take Aahara dominant in Kashaya, Tikta, and MadhuraRasa and Ghrita in more quantity. In Vataj dominant snake bite, Ghrita dominant Aahara is advised.
When the effect of poison does not diminish even after doing curative measures like chanting and drug administration, after completion of fifth stage and before the starting of seventh stage, advised for the administration of Prativisha (counter poison). Charaka advised to take SthavarVisha for Jangam envenomation and should made to be bitten by poisonous animals including snake for Sthavar poisoning because of their opposite nature of poison, that counteracts the effect of each poison. Sushruta has given an example of EksarYoga,in context of snake bite envenomation, this Yoga contains Arka,that comes under SthavarVisha, which can be used to pacify the venomous effect of Snake bite. Vagbhat also accepted and elaborated that mostly Sthavar Visha(inanimate) shows the properties of Kapha predominancy with upward movement in nature where Jangam Visha(animate) mostly shows properties of pitta with downward movement in nature. Hence, the properties of Sthavar and Jangam Visha shows opposite in their action. So, due to their opposite action, Sthavar Visha is use to counteract of Jangam Visha and vice versa.
It is very important procedures and a group of different treatment modalities has been performed. Charak advised to do these procedures in sixth stage. These procedures should perform through different forms of measures have been used to bring back the senses. The procedures like Nasya should be done to the patient showing features of unconsciousness, upturned of eye etc. Similarly, Kaakpada (venous section) by giving incision is performed immediately to the veins of patient’s forehead and extremities in the shape of cow’s feet. After that application of flesh or decoction of paste of Charmakasha over the scalp and drum is coated by Agada, then ring in loud sound.
There are certain Lepa Kalpana has been mentioned to neutralized the poisonous effect of various poison or combination of poison. It is the semisolid form of medications prepared from various drugs and is indicated in poisoning. Vaghbhat recommended HimwaanAgad for Lepa to the patient of Mandali Snake bite. And local application of Charati, Nakuli or TikshnaMoolaVisha for Darvikar Snake bite.
It is the one of the most special types ancient classical therapy which is used for the resuscitation of patient when showing the sign of death or is going apparently to death. Charak, in 23 chapter of Chikitsasthan advised to take powder of Palashaseed with bile of peacock in eight stages of Vega with patient appear to death. In classical text various preparations [Table 5] have been mentioned which is used for the resuscitation of patient.
|Table 5: different kind of Mritasanjivaniyoga, mentioned in classical text|
Click here to view
In allopathic science, it has been clearly defined about life saving drugs i.e., anti-snake venom and different procedures like CPR (Cardiac Pulmonary Resuscitation). It can be considered as the term Mritusanjivani.
| Discussion|| |
Some snakes defined in Ayurveda lie under venomous and non-venomous. The poisonous snakes like Darvikar, Mandali, Rajimaan etc. have more or less similar poisonous action like neurotoxic, vasculotoxic and myotoxic poison respectively. Also, many non-poisonous snakes have found, thus there is no need to be discussed about their management. Chaturvisanti Vishochikitsopakram has mentioned in classical text for the treatment of venomous envenomation. Among them some of treatment modalities are practicing in modern ere. Similar procedures are also applying form modern science but with their own modern name. In Ancient period, various kinds of Chanting were applying for treatment of venomous conditions. In modern, study have found the significance of Mantra in venomous condition like snake bite, by inhibiting the secretion of adrenergic receptor and prevents from stimulation of nervous system. Thus, provides mental relaxation which slow down the speed of venom flow into systemic circulation. Mantras have positive phrases or words and brings the positive energy that decreases the negative thoughts or stress.Arista-bandhana is another procedure that prevents from entering of venom into systemic circulation. But contemporary science thought that it may cause necrosis of tissues and brings further complication. So, do not allow this procedure. Similarly, Utkartana is another procedure that helps to eliminate venom along with vitiated blood from the bite site. In modern, they thought that incision on bite site may lead to difficulty in diagnosing the type of snake bite envenomation. So, they avoid incision. Some study found that NPWT, the procedure is commonly applied in different disease condition to draw out vitiated fluid but not specified for snake bite. NPWT inhibits systemic inflammatory reaction and also inhibits compartment syndrome. So, this procedure could be helpful for snake bite envenomation by inhibiting from releasing of inflammatory mediators. Similarly, Aaushadha process is commonly using from both Ayurveda and modern science, either in the form of anti-snake venom, or other kinds of medicines from modern or different kinds of medicines extracted from plant, animal, or mineral. In Ayurveda various kinds of Agad formulations have been mentioned in different classical texts. These can be used either externally or internally in various animate bites like Snake. Remaining modalities of treatment like Nishpidan, Chushana, Raktamokshana, HridayavaranChikitsa, Anjana, Nasya, Dhuma, Leha etc. Karma are not usually in practice because of the lack of researches in this field. Nishpidan karma creates the pressure around bite site, results to expel poison of snake and hence decreases the concentration of poison around bite site. Likewise, in place of Chushana somewhere vacuumed creator equipment is in use for snake bite to drag out venom from the body. Parisheka (sinking into cold water) although not in use, the cold water shows Sthambhan (inhibition of movement), which slow down the movement of venom either into circulation or into various organs that prolonged the venomous effect in body. Rakta Mokshana is one of the important procedures in Ayurveda. Sushruta has given the indications for each VishaVega of specific snake bite. During blood-letting, the venom eliminates out along with blood. Charaka focused on to protect of heart first by HridayavaranChikitsa, which could be the best possible treatment and advocated as first line of treatment in all type of poisoning conditions including Snake bite management. It is intended to protect the heart from venom/poison by taking Madhu, Ghrita, Suddha Gairik etc. Because poison will stay only for few minutes at bite site then enters into systemic circulation where it shows harmful effect to heart. Similarly, in classical text certain Mritasanjivani (recall the life from going apparently to death) like preparations of Agad have been mentioned alike CPR and anti-snake venom in modern science. Most of these Agad contains bile of cows or horse which is supposed to enhance the bioavailability of drugs. Thus, all those treatment modalities through Ayurveda need research on their mechanism of action in order to prove its scope in modern era.
| Conclusion|| |
Caturvimsati Vishachikitsopakrama have their own important value for the management of snake bite and that have great role even in emergency management. It can be observed that most of the treatment modality through Ayurveda have based on the same principle as that of modern. It is scientific approachable, easily accessible, costly effective, time saving and can be performed anywhere. So, these procedures should be researched and implemented with the advancement of this era.
Financial support and sponsorship
ITRA, Jamnagar, Ministry of AYUSH.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]