Management of snake bite: An ayurvedic overview

Management of snake bite: An ayurvedic overview ISSN: 2394-0026 (P)Review Article ISSN: 2394-0034 (O)Management of snake bite: An ayurvedic overview Sujit B Koshire*, Vishnu P JoglekarAgadtantra Department, Tilak Ayurved Mahavidyalaya, Pune, India *Corresponding author email: [email protected] to cite this article: Sujit B Koshire, Vishnu P Joglekar. Management of snake bite: An ayurvedicoverview. IAIM, 2015; 2(2): 152-160.Available online at www.iaimjournal.comReceived on: 14-01-2015 Accepted on: 26-01-2015AbstractAyurveda has its own unique way of approach towards the management of visha, and is discussedwith the concepts of current science. Snake bite remains an underestimated cause of accidentaldeath in India. Estimates of snakebite mortality in India vary from approximately 1,300 to 50,000annually. Considering this, World Health Organization added snake bite to their list of neglected hotdiseases and designed an exclusive protocol for its management. Acharya Charaka has given 24Upakramas to counter the cases of poisoning, including Mantras. These can be categorized intodifferent sets of sub divisions for easy and scientific understanding. In the current attempt, effortswere made to provide certain justifications to these classical remedial measures with specialemphasis on the measures that restrict the entry of poison into systemic circulation.Key wordsAyurveda, Mantra Chikitsa, Poisoning, Upakrama, Sarpavisha, Snake bite.Introduction Indian cobra (Najanaja), Common kraitIndia is such a country, where snake bite is very (Bungaruscaeruleus), Russell’s vipercommon emergency [1, 2]. It is reported thatthere are only 52 venomous snakespecies out of (Daboiarusselii) and Saw scaled viper216 species in India [3]. Yet, every year 50,000Indians mostly tribals and villagers, die in (Echiscarinatus) are the four venomous snakes250,000 incidents of snake bite [4] with highincidences in the states of Tamil Nadu, West found in India. Romulus Whitaker called themBengal, Maharashtra, Uttar Pradesh, and Kerala.Five families of poisonous snakes viz. Colubride, the “Big Four” which are mainly responsible forElapidae, Hydrophidae, Viperidae and Crotalidaehave been identified in India [5]. Commonly the Indian snake bite mortality [6]. Recently a new species of krait named as Bungarussindanus/ walli are found in Maharashtra. This species has shown 100% fatality in spite of anti snake venom serum (ASV) [7].International Archives of Integrated Medicine, Vol. 2, Issue 2, February, 2015. Page 152Copy right © 2015, IAIM, All Rights Reserved.

Management of snake bite: An ayurvedic overview ISSN: 2394-0026 (P)Description of snake bites ISSN: 2394-0034 (O) Hence, asmallor no amount of poison will beDescriptions on different types of snakes, their injected through such bites.respective characters along with nature of Wet bite (type 2)poisoning, treatment modalities etc. have been These are the actual poisonous bites. If thecategorically emphasized in Ayurvedic classics. victim comes across with a violent snake, whichSushrutaacharya described four types of snake is hungry and behind its prey; such bites will bebites as [8] more poisonous as bulk amount of toxin enters into the systemic circulation. As per the • Sarpita - Inflamed deep wound, blackish available statistical data, such bites are very less in color. in number. • Radita - Superficial wound, red or bluish in color. This bite is considered as less poisonous.• Nirvisha - Non-poisonous bite. May be a Treatment modalities dry bite. Signs of inflammation cannot WHO provided a protocol for snakebitebe observed. treatment in 2005 [12] and emphasized the first• Sarpangabhihata - Actual bite will not aid measures as following.take place in this type. • Reassure the victim who may be very anxious.Symptoms of snake bite • Immobilize the bitten limb with the splint or sling (any movement orAccidental contact with snake will lead to the muscular contraction increases themanifestation of symptoms like local absorption of venom into the bloodinflammation (daah) etc. This kind of stream and lymphatic circulation).manifestation has been explained by Charaka [9]as ‘Shankavisha’ (suspicious poisoning), causes • Avoid any interference with the woundfever, vomiting, fainting and even feeling of as this may introduce infection, increaseburning sensation or exhaustion, delusion and absorption of venom and increase localdiarrhea, manifests because of fearful complex. bleeding. Treatment in Ayurveda has been categorized into ‘Chatur vimshatiCategories of bites upakramas’ by Acharya Charaka as perAcharya Vagbhata categorized the bites in to Table - 1 [13].two [10] viz. Savisha (poisonous) and Nirvisha In this context, the commentator mentions not(non poisonous). This classification is similar to follow all these 24 modalities in all cases ofwith that of modern classification, which poisonings. One has to examine and decide thecategorized the snake bites in to two viz. Dry procedure justifiable for that specific conditionand Wet bites. [14]. Based on the probable purpose of the treatment, these Upakramas can be grouped inDry bite (type 1) to five sets of sub- divisions as per Table - 2.A kind of bite, where no or minimal venom isinjected. It occurs in between 25-50% of snake It has been specified by Charaka that “withoutbites [11]. These bites occur as matter of entering in the blood stream, poison cannotdefense or to give warning signals. The intension damage the tissues [15]. Similar concepts haveof snake in this situation is basically to escape. been expressed by Vagbhata, who says thatInternational Archives of Integrated Medicine, Vol. 2, Issue 2, February, 2015. Page 153Copy right © 2015, IAIM, All Rights Reserved.

Management of snake bite: An ayurvedic overview ISSN: 2394-0026 (P)“poison cannot damage the tissue without ISSN: 2394-0034 (O) the individual and works in the similarentering into the blood. Even an atom of poison ways of mantras.can spread all over the body along with bloodand can damage the system [16]. Considering Sushruta goes on emphasizing the method ofthese; priority has been given by the application and says that, it should be appliedcommentator towards preventing the entry of four inches above the site of the bite [23].poison in to the systemic circulation. Sushruta further stresses on the precautions to be observed during the procedure. BandhanaIn addition, Mantra has been exclusively with Arista should not be too tight or loose. Heemphasized by Charaka and preferred to be prefers not to apply much pressure. Applyingfollowed immediately after the suspected cases tourniquet with greater pressure for longerof poisonings. duration, blocks the underlying main vessels arteries, lymph and nerves, which furtherMantra interferes the circulation and nerve impulses.Chakrapani prefers Mantra as foremost and par This result in Shoonya Gatrata (numbness)excellence upakrama among others, which Shoon Gatrata (oedema) and PutiKlinna Mamsanullifies the poison without fail [17]. Charaka (gangrene) [24]. This concept is well acceptedfurther said that, Mantra occludes the blood even by the modern medical science.vessels, prevents the entry of poison in to thesystemic circulation and protects from further Agniinfections [18]. When the bite is on a part of the body that cannot be subjected to arishtaa bandhana suchChanting of Mantras is a specific rhythm which is as the trunk or face, suction, excision andsupposed to build confidence in victim and help burning the site are indicated by Charaka [25].in relieving anxiety [19]. They may stimulate The bite spot should be burned with red-hotsympathetic nervous system and strengthen the gold or iron. Except in the cases of viper bite,peripheral blood vessels, which helps in because in this case pitta is increased and theirmaintaining the normal blood flow to the vital burning is contraindicated as toxicorgans. Thus Mantra may have a vital role in manifestations may aggravate [5].reassuring the victim. Utkartana, Nishpidana and ChushanaArishta Bandhana These modalities are under debate. With anChakrapani prefers to apply tourniquet, before intension to prevent further damage to thethe poison enters in to the systemic circulation underlying soft tissue and other structures like[20]. Vagbhata said that, the blood vessels nerves, blood vessels etc. [26]. Thesecannot carry the poison, if tourniquet is applied procedures are beneficial where medicalproperly [21]. Sushruta categorized tourniquet facilities are far away and specific anti-venom isinto two category as below [22]. not available. Acharya Sushruta said that, if no• Mantra Arista – Protective charm, treatment is given for poisoning, that poison willimpregnated with Mantra kill the victim within 2-3 hours (Muhurta) [27].• Mantra Rahita Arista – Actual Tourniquet Mantra Arista will be Vagbhata said that, the poison will stay at thebeneficial in boosting the confidence if site of the bite at least for 100 Matrakala andInternational Archives of Integrated Medicine, Vol. 2, Issue 2, February, 2015. Page 154Copy right © 2015, IAIM, All Rights Reserved.

Management of snake bite: An ayurvedic overview ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)hence proper local measures are to be taken to Vamanameliminate the poison from the site of the bite Person should be made to vomit, for mitigatingand its spreading into the system [28]. Charaka the effect of residual poison, especially those ofadvocates incision over the bite (excluding the kapha predominant constitution, those bitten byvital points), compression and sucking with snakes which are of kapha temperament, andtaking proper care. The commentators advocate those bitten on parts of the body above theto keep flour of Yava or cloth or little amount of umbilicus [32].sand on oral cavity prior to sucking the poisonfrom the site of the bite [20]. This may be a kind When kapha gets increased and accumulates inof precautionary measures, which prevents the the heart, producing feeling of heaviness,contact of poison with oral mucosa. Special salivation and nausea, hence he should be madeinstrument like Shringa were also preferred for to vomit using emetic drugs which are anti-this purpose, which are comparatively safer. poisonous [30].Raktamokshana and Prashamana VirechanamWhen the poison is spread to the entire body, The persons of pitta constitution, bitten by abloodletting is most potent treatment. Sushruta snake of pitta predominant features of the bitesaid that, siravedha at the site of bite or being in parts below the umbilicus, the poisonbloodletting by cutting the veins at extremities found localized in the large intestineand forehead is effective in removing the toxic (pakwashaya) should be made to drink ablood from the system [29]. After bloodletting purgative drugs [33].the residual blood deranged by the heat ofpoison, should be suppressed or stabilized by Hridayavaranaexternal applications of medicinal pastes or byirrigation with water or fluids medicated with It is a method of conditioning the body tocold potency drugs [5]. protect the hridaya from visha-both ingested and injected – with the use of some specificPratisaranam and Prativisham drugs. Poison by its penetrating property weakens the heart, so in order to protect it; theIf blood is not coming out from the bite area by patient should be made to drink ghee, gheeincision or any procedure then it is dangerous mixed with honey or anti-poisonous drugsfor patient because blood being affected by added with more of ghee [34].poison, the constitution is deranged and thusthe patient expires. So it should be impelled by Anjanam and Dhumamapplication of rubbing powders such as Curcumalonga (Rajani), Rock salt (Saindhava), Piper Anjanam means collyrium, should be applied inlongum (Pippalee), Piper nigrum (Maricha), dry a case of poisoning that develops swellingZinger officinale (Shunt’hee) etc. So due to around the eyeball, somnolence, discolorationapplication of these powder formed drugs, and turbidity of the eyes and where the victimenhances the flow of blood or body fluids [30]. visualizes all objects as discolored [35]. It is saidCharaka says that animate poison is the antidote that after a bite of sarpita type of snake,to inanimate poison and viceversa because of Anjanam is given in 3rd and 7th stage (vega) oftheir reverse action so the treatment is given poisoning. Smoke or fumes arising from antitoxicaccordingly [31]. materials are given for predominant conditionsInternational Archives of Integrated Medicine, Vol. 2, Issue 2, February, 2015. Page 155Copy right © 2015, IAIM, All Rights Reserved.

Management of snake bite: An ayurvedic overview ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)of upper body part (urdhwajathru) vitiation due this medicine is to be used as collyrium or eyeto poison [36]. drops [41].Leham and Aushadham Mruta SanjeevanamWhen mouth becomes dry due to poison, then This is a special Agada (anti-poisonous drugs)Linctus usually of ghee and honey is given called used for resuscitation when the conditions ofas leham. After that, different types of anti- poisoning where the patient is apparently dead,poisonous drugs are administered through oral but life energy remains hidden in the body.cavity by incantation of mantra or without Finely powdered of seeds of Buteafrondosamantra and other than this all types of internal (Palaas’ha) mixed with half peacock’s bile act asadministration of medicaments such as water good resuscitative anti-poison in almost deadextract (Kashaaya), pills, nasal medication in the patients. The formulation of Solanummelongena,form of drops(Nasya), collyrium, medicated Molasses, Soot, Azadirachtaindica and cow biledrinks comes under this jurisdiction [37]. acts in similar way [42].Parisheka, Avagaha and Lepa ConclusionAfter proper elimination of poison, the incised The Upakramas have their own significance inarea is to be cleaned thoroughly and medicated neutralizing the poison in different ways.pastes are too applied. For these purposes, the Though there is certain ambiguity in thedrugs and other liquids which are sheeta(cool) in approach as compared to the Modern medicalnature have been preferred [38]. The cold science; the treatment modalities emphasized incharacter of the drug helps in further infections Ayurveda have a Great significance and arein wound also helps in contraction of local blood valuable particularly in remote areas, wherevessels, preventing further spread of remaining medical Facilities are inadequate.poison if any at the site. ReferencesNasyam and Upadhanam 1. Philip E. Snakebite and scorpion sting.When the patient is unconscious, nasal In: Srivatava RN editor. Pediatric andmedications are given in the form of fine Neonatal Emergency Care. Jaypeepowders. Drugs having pungent properties are Brothers; New Delhi, p. 227-34.commonly given for this purpose [39]. Afterthat, deep incisions are made on the vortex and 2. Mulay DV, kulkarni VA, Kulkarni SG,flesh with blood or the absorbent barks of the Kulkarni ND, Jaju RB. Clinical profiles oftree are placed [40]. snakebites at SRTR Medical college Hospital, Ambajogai(Maharashtra),Sajna Samstapanam Indian Medical Gazette 1986; 131: 363- 6.Sage Charaka states that during the sixth phaseof poison (visha) which develops 3. www.snakebiteinitiative.org/india.unconsciousness, this measure is to be adopted. Retrieved on 16.03.2012.Fine powder of Curcuma longa, Rubiacordifolia,Piper nigrum, Piper longum drugs is mixed with 4. Beejayini Mohapatra, et al. Snakebitethe bile of cow shall to be consumed. In mortality in India: A Nationallycommentary Aayurvedadeepika, it is stated that Representative Mortality Survey, Articles from PLOS Neglected Tropical Diseases are provided here courtesy ofInternational Archives of Integrated Medicine, Vol. 2, Issue 2, February, 2015. Page 156Copy right © 2015, IAIM, All Rights Reserved.

Management of snake bite: An ayurvedic overview ISSN: 2394-0026 (P)Public Library of Science, v. 5(4); apr ISSN: 2394-0034 (O) 16. Astanga Hridaya, uttarsthana, 36/14,2011. Chaukhamba Surabharti Prakashan,5. Dr. Huprikar, Dr. V. P. Joglekar. Textbook Varanasi, Reprint, 2010.of Agadtantra, First edition, R.S.M 17. Chakrapani on Charaksamhita,Publication, Pune, 2008. Chikitsasthana, 23/35, Chaukhamba6. K.G. Sam, M.F. Khan, S. Peerally, P.G. Surabharti Prakashan, Varanasi, Reprint,Kumar, P.G Rao. Snakebite 2009.Envenomation: A Comprehensive 18. Charaksamhita, Chikitsasthana, 2/61,valuation of Severity, Treatment and Chaukhamba Surabharti Prakashan,Outcome in a tertiary care south Indian Varanasi, Reprint, 2009.Hospital. The internet Journal of 19. Pratap G, Narayana Prakash B, SuhasEmergency Medicine, 2009; 5(1). Shetty. Critical Analysis of Mantra7. Neelimkumar Khaire, A Guide to the Chikitsa, AYU, 2008; 29(2): 74.snakes of Mah, Goa & Karnataka, Indian 20. Charaksamhita, Chikitsasthana, 23/38,Herpetological society, 2006. Chaukhamba Surabharti Prakashan,8. Sushruta, Sushrutsamhita, Ayurveda Varanasi, Reprint, 2009.tatwasandeepika, hindi commentary, 21. Astanga Hridaya, uttarsthana, 36/43,edited by kaviraj Ambikadutt Shastri, Chaukhamba Surabharti Prakashan,Kalpsthana, 4/14-9, Chaukhamba Reprint, 2010.Sanskrit sansthan, Varanasi, edition- II, 22. Sushrutsamhita, Kalpasthana, 5/8,1997, p. 38. Chaukhamba Surabharti Prakashan,9. Charaksamhita, Chikitsasthana, 23/221, Varanasi, Reprint, 2008.Chaukhamba Surabharti Prakashan, 23. Sushrutsamhita, Kalpasthana, 5/3,Varanasi, Reprint, 2009. Chaukhamba Surabharti Prakashan,10. AstangHridaya, uttarsthana, 36/18, Varanasi, Reprint, 2008.Chaukhamba Surabharti Prakashan, 24. Sushrutsamhita, Kalpasthana, 5/56,Varanasi, Reprint, 2010. Chaukhamba Surabharti Prakashan,11. http://www.emedicinehealth.com/snak Varanasi, Reprint, 2008.ebite/article_em.html. Retrieved on 25. Charaksamhita, Chikitsasthana, 23/45,21.03.2012. Chaukhamba Surabharti Prakashan,12. Guidelines for the clinical management Varanasi, Reprint, 2009.of snakebites in South East Asia region, 26. Sushrutsamhita, Kalpasthana, 5/5,WHO, South East Asia, Delhi, 2005. Chaukhamba Surabharti Prakashan,13. Charaksamhita, Chikitsasthana, 23/35-7, Varanasi, Reprint, 2008.Chaukhamba Surabharti Prakashan, 27. Sushrutsamhita, Kalpasthana, 4/36,Varanasi, Reprint, 2010. Chaukhamba Surabharti Prakashan,14. Charaksamhita, Chikitsasthana, 23/179, Varanasi, Reprint, 2008.Chaukhamba Surabharti Prakashan, 28. AstangaHridaya, uttarsthana, 36/38-9,Varanasi, Reprint, 2010. Chaukhamba Surabharti Prakashan,15. Charaksamhita, Chikitsasthana, 23/40, Reprint, 2010.Chaukhamba Surabharti Prakashan, 29. Charaksamhita, Chikitsasthana, 23/39,Varanasi, Reprint, 2010. Chaukhamba Surabharti Prakashan, Varanasi, Reprint, 2009.International Archives of Integrated Medicine, Vol. 2, Issue 2, February, 2015. Page 157Copy right © 2015, IAIM, All Rights Reserved.

Management of snake bite: An ayurvedic overview ISSN: 2394-0026 (P)30. Dr. Nitin Urmaliya, Textbook of ISSN: 2394-0034 (O) 37. Astanga Sangrah, uttarsthana, 40/87,Agadtantra, First edition, Chaukhamba Chaukhamba Surabharti Prakashan,Publishers, Varanasi, 2011. Reprint, 2010.31. Charaksamhita, Chikitsasthana, 23/50, 38. Charak samhita, Chikitsasthana, 23/41,Chaukhamba Surabharti Prakashan, Chaukhamba Surabharti Prakashan,Varanasi, Reprint, 2009. Varanasi, Reprint, 2009.32. Sushrutsamhita, Kalpasthana, 5/39, 39. Charak samhita, Chikitsasthana, 23/68,Chaukhamba Surabharti Prakashan, Chaukhamba Surabharti Prakashan,Varanasi, Reprint, 2008. Varanasi, Reprint, 2009.33. Sushrutsamhita, Kalpasthana, 5/40, 40. Charaksamhita, Chikitsasthana, 23/67,Chaukhamba Surabharti Prakashan, Chaukhamba Surabharti Prakashan,Varanasi, Reprint, 2008. Varanasi, Reprint, 2009.34. Charaksamhita, Chikitsasthana, 23/46, 41. Sushrut samhita, Kalpasthana, 5/43, 49,47, Chaukhamba Surabharti Prakashan, Chaukhamba Surabharti Prakashan,Varanasi, Reprint, 2009. Varanasi, Reprint, 2008.35. Charak samhita, Chikitsasthana, 23/69, 42. Charak samhita, Chikitsasthana, 23/54-Chaukhamba Surabharti Prakashan, 60, Chaukhamba Surabharti, Prakashan,Varanasi Reprint, 2009. Varanasi, Reprint, 2009.36. Charak samhita, Chikitsasthana, 23/99,Chaukhamba Surabharti Prakashan,Varanasi, Reprint, 2010.Source of support: Nil Conflict of interest: None declared.International Archives of Integrated Medicine, Vol. 2, Issue 2, February, 2015. Page 158Copy right © 2015, IAIM, All Rights Reserved.

Management of snake bite: An ayurvedic overview ISSN: 2394-0026 (P)Table – 1: Chatur vinshati Upkarmas. ISSN: 2394-0034 (O)Treatment measure Probable comparisonMantram Chanting MantrasArishtabandhanam Application of tourniquetUtkartanam Incision over the biteNishpeedanam CompressionAchushanam Sucking through the siteAgni Thermal cauterizationParishekam Sprinkling waterAvagaham Water bath (Immersion)Raktamokshana Bbalotohd) lettingVamanam EmesisVirechanm PurgationUpadhanam Medication on incised scalpHrudayavaranam Protection of heartAnjanam Medicated collyriumNasyam Medicated nasalDhumam MinseudfifclaattieodnssmokingLeham Medicated linctusesAushadham Anti-poisonous drugsPradhamanam Medicated snuffingPratisaranam Local applicationsPrativisham Specific antidotesSajnaSamstapanam ResuscitationLepam Application of medicatedMrutaSanjeevanam RevivationInternational Archives of Integrated Medicine, Vol. 2, Issue 2, February, 2015. Page 159Copy right © 2015, IAIM, All Rights Reserved.

Management of snake bite: An ayurvedic overview ISSN: 2394-0026 (P)Table – 2: Subdivision of Chatur vinshati Upkarmas. ISSN: 2394-0034 (O)Purpose Upkarma Total UpkarmasThe measure that restrict the entry of poison into 2-8, 23 8systemic circulationElimination therapy 9, 10, 11, 15, 16, 19 6 13, 22, 24 3Supportive, Symptomatic treatment 1, 17, 18, 21 4Counteracting medications, Antidotes etc 12, 14, 20 3Topical application Total 24International Archives of Integrated Medicine, Vol. 2, Issue 2, February, 2015. Page 160Copy right © 2015, IAIM, All Rights Reserved.