Introduction of Agnikarma & Ayurvedic management of Burn

Dr. ALOK KUMAR VERMA

M.S. (AY), (Ph.D.)

LECTURER DEPARTMENT OF SHALYA TANATRA

NEIAH, SHILLONG

अग्नि��कर्म� Agnikarma

The procedure performed by using the Agni (HEAT) to cure the various disorders is known as Agnikarma.

The therapeutic use of agni is described as Agnikarma. In Sushrut samhita sutra sthan chapter .12

Acharya Sushrut included this in the Anushastra i.e. parasurgical procedures.

Agnikarma could be correlated to thermal cauterization.

Why Agnikarma ???

तद्द�धा�ां रोगाणार्मपु�र्भाा�वादे्भषजशस्त्रक्षारैरसाध्या�ां तत्साध्यत्वाच्च

su.su. 12/3

The disease treated with proper agnikarma has no chance of recurrence. It cures the disease which are not treatable with medicine, surgery and kshar karma (chemical cauterization).

Types of agnikarma

Acharya sushrut described agnikarma of four types 1. Tvacha (Skin) 2. Mansa (Muscles) 3. Sira , Snayu ( vessels and ligaments, tendons) 4. Sandhi and Asthi ( joints and bones)

But some other says only tvacha and mansa

Types of Agnikarma

According to pattern of Agnikarma

1. Valaya (circular )

2. Bindu (pointed) .3. Bilekha (straight )

4. Pratisaran (rubbing) Some Acharya added some more shape like swastika , astapad etc. The classification was done on the basis of shape of tip of shalaka as

well as method of performing Agnikarma.

Instruments/ upkaran used in Agnikarma

पिपप्पल्यजाशकृद्गोदन्तशरशलाकास्त्�गता�ां i.e. for vat kaphaj skin disorders. (su.su. 12/4)

जाम्बवौषे्ठतरलौहा, र्मांसगता�ां i.e. for vat kaphaj muscular disorders. (su.su. 12/4)

क्षौद्रगुडस्�ेहाः सिसरास्�ायुसन्ध्यस्थि6गता�ार्म् (su.su. 12/4)

i.e. For vat kaphaj disorders of vessels, ligaments, joints and bones.

Panch dhatu shalaka

Components of Panchadhatu Shalaka

Tamra (copper) → 40%Loha (iron) → 30%Yashada (zinc) → 10%Rajata (silver) → 10%Swarna (Gold) → 10%

Acharya Sushrut described these various measures of Agnikarma for the purpose of heat regulatios

Indication of Agnikarma

त्वङ्मांससिसरास्�ायुसन्ध्यस्थि6स्थि6तेऽत्युग्ररुजिज वायावुस्थि>तकठि@�सुप्तर्मांसव्रणे ग्रन्थ्यशCऽबु�दर्भागन्दरापचीश्लीपदचर्म�कीलपितलकालकान्त्रवृजिHसन्धिJसिसराचे्छद�ाठिदषु �ाडीशोणिणतापितप्रवृणिNष ु चाग्नि��कर्म� कुया�त् (su.su. 12/10)

The pain aggravated by vata in tvacha , mans, sira, snayu, sandhi and asthi .

Chronic wound having some hard elevated tissue. Cystic lesion, hemorrhoids,

tumor, fistula, sinus lymphadenopathy, filarial, skin tag, hernia, joints disorders,

to stop bleeding from cut vessels.

Contraindications

तत्राग्नि��कर्म� सव�तु�षु कुया�दन्यत्र शरदग््रीष्र्माभ्यां; तत्राप्यात्ययियकेऽग्नि��कर्म�साध्ये व्याधौ तत्प्रत्य�ीकं पिवधिधं कृत्वा (su.su. 12/5)

अथेर्मा�ग्नि���ा परिरहरेत-् पिपNप्रकृपितर्मन्तःशोणिणतं णिर्भान्नकोष्ठर्म�ुHतृशल्यं दुब�लं बालं वृHं र्भाीरुर्म�ेकव्रणपीपिडतर्मस्वेद्यांशे्चपित (su.su. 12/14)

All types of pittaj and raktaj disorders, patients with concealed bleeding, intestinal perforation, retain foreign body, weak, children , old age person, and patients with multiple wounds and who are not fit for swedana arma .

Samyak dagdha lakshana(Features of perfect Agnikarma )

शब्दप्रादुर्भाा�वो दुग�Jता त्वक्सङ्कोचश्च : त्व�द�धे

कपोतवण�ताऽल्पश्वयथुवेद�ा शुष्कसङ्कुसिचतव्रणता च : :र्मांसद�धे

कृष्णोन्नतव्रणता स्रावसयिन्नरोधश्च : सिसरास्�ायुद�धे

रूक्षारुणता कक� शस्थि6रव्रणता च : सन्ध्यस्थि6द�धे

(su.su. 12/8)

Pre / post procedure care

रोगस्य सं6ा�र्मवेक्ष्य सम्यङ्�रस्य र्मर्मा�णिण बलाबलं च व्याधिधं तथतुc च सर्मीक्ष्य सम्यक् ततोऽव्यवस्येजिद्भषगग्नि��कर्म� (su.su. 12/12)

The careful examination of patients as well as disease is must prior to the Agnikarma procedure.

तत्र सम्य�द�धे र्मधुसर्पिपंभ्या�र्मभ्यङ्गः| (su.su. 12/13)

The madhu (honey) and ghrita (Ghee) should be applied after the agnikarma procedure.

Procedure of Agnikarma After complete examination of patient and taken written consent ,

first identify the site of agnikarma. Injection T.T. 0.5 ml IM should be given as prophylaxis. Patients should be taken in proper position, must be in ease. After marking site, Clean the area with triphla kwath . Take the red hot shalaka and touch the shalaka on identified marks

for few seconds and withdraw it followed by immediate application of ghritkumari swaras ( aloe vera pulp).

Apply bandage after application of madhu + grita or pouring of haridra powder with triphla churna.

Patient should be advised to avoid wet that area up-to 24 hrr.

इतरथा / प्रमाद दग्ध Etartha / pramad dagdha

इतरथा द�धयिर्मपित प्रकारान्तरेण वैद्यादृते (su.su. 12/15) प्रर्मादाद्द�धर्म् | तत्रेत्याठिद द्रव्यं न्धिस्��धं सर्पिपंराठिद, रूकं्ष द्रव्यं काष्ठपाषाणलोष्टाठिद

( Dalhan comm.)

When person got burn accidently that is different from the Agnikarma described earlier is called etartha or pramad dagdha i.e. burn injury.

It is of two types Wet and dry. Acharya stated that wet burn is more painful than dry because in wet

burn latent heat penetrates deeper & damages the tissues of body.

Types of Agnidagdha (burn injury)

तत्र प्लुषं्ट दुद��धं सम्य�द �धर्मपितद�धं चेपित चतुर्पिवंधर्मग्नि��द�धर््म |

(su.su.12/16)

प्लुष्ट

दुद��ध

अपितद�ध

प्लुष्ट दग्ध तत्र यपिiवणc प्लुष्यतेऽपितर्मातं्र तत्

प्लुष्टं (su.su.12/16)

The affected part become different in color from skin along with very severe burning sensation.

Condition almost similar to first degree burn.

दुद�ग्ध

यत्रोणिNष्ठन्तिन्त स्फोटास्तीव्राश्चोषदाहरागपाकवेद�ाणिश्चराच्चोपशाम्यन्तिन्त तद्ददु��धं; (su.su.12/16)

The burn injury having blisters, severe burning sensation, redness, suppuration and pain remains for very long time, condition almost similar to advance II and III degree burn.

सम्यक दग्ध

सम्य�द�धर्म�वगाढं तालवणc सुसंस्थि6तं पूव�लक्षणयुकं्त च (su.su.12/16)

The burn injury which is not too deep neither very superficial , having color like Asian palm fruit (taal phal varna), tissues remains on their own site and having other sign symptoms described earlier.

This is not considered as injury when performed for the therapeutic purpose. If the above sign and symptoms occurs that indicate the perfect Agnikarma.

अतितदग्ध अपितद�ध े र्मांसावलम्ब�ं गात्रपिवश्लेषः

सिसरास्�ायुसन्ध्यस्थि6व्यापाद�र्मपितर्मात्रं ज्वरदाहपिपपासार्मूच्छा�श्चोपद्रवा र्भावन्तिन्त, व्रणश्चास्य सिचरेण रोहपित,

रूढश्च पिववणC र्भावपित |

(su.su.12/16) The injury affecting the whole tissue as skin subcutaneous

tissue, muscles , vessels , tendons, ligaments and exposing to other deeper structure.

The patients having high grade fever, burning pain, increase thirst, syncope and other features of dehydration.

The wound healing delayed with discoloration of particular part.

The condition is almost similar to advanced 3rd degree burn .

Management of Agnidagdha (BURN)

प्लुष्ट दग्ध चि�तिकत्सा “ प्लुष्टस्याग्नि��प्रतप�ं काय�रु्मष्णं तथौषधर््म | (su.su.12/19)

शरीरे स्विस्वन्नर्भाूयियषे्ठ स्विस्वन्नं र्भावपित शोणिणतर्म् प्रकृत्या हु्यदकं शीतं स्कन्दयत्यपितशोणिणतर्म् | (su.su.12/20)

” तस्र्मात् सुखयपित ह्युष्णं � तु शीतं कथञ्च� (su.su.12/21)

Acharya Sushrut mentioned warm medicine for the local application as well as internal medication.

Why warm ???...

Superficial burn

Injury causes water loss from that area

Blood concentration increases

Application of Cold

Coagulation of blood in vessels

Reduced blood supply of that area

Delayed healing

May leading to Necrosis

दुद�ग्ध चि�तिकत्सा शीतार्मुष्णां च दुद��धे पिvयां कुया�जिद्भषक् पु�ः |

घृतालेप�सेकांस्तु शीता�ेवास्य कारयेत् || (su.su.12/22)

Acharya Sushrut mentioned both warm and cold medication for this type of burn injury.

Acharya Dalhan commented on this explaining that for the deep burn internal medicine with cold active principle should be used and if burn injury is superficial then medicine with the warm active principle should be used.

But for the external application only cold application should be used.

Burn injury ( Durdagdha )

Internal medication external medication

Deep - cold cold

application Superficial - warm cold

application

सम्यक दग्ध चि�तिकत्सा सम्य�द�धे तुगाक्षीरीप्लक्षचन्द�गैरिरकैः | सार्मृतैः सर्पिपंषा न्धिस्��धैरालेपं कारयेजिद्भषक् ग्राम्या�ूपौदकैश्चै�ं पिपष्टैर्माcसैः प्रलेपयेत् | पिपNपिवद्रयिधवच्चै�ं सन्ततोष्र्माणर्माचरेत् | (Su.Su. 12/23-24) As per Acharya Sushrut above said medicines should be

used in post agnikarma procedure for local as well as internal medication.

Acharya Sushruta added that if person dosen’t get relief from above medicine that surgeon should follow the line of treatment like abscess.

Acharya Sushrut stated lot of medicine for the treatment of abscess , in which most of them are having pittashamak property.

Paste of तुगाक्षीरी ( Tugakshiri ), प्लक्ष Plaksha, Chandan, amrita & Gairik with Gritha can be used as ointment for local application.

Paste of flesh of some animals like horse, pig etc may also be used as lepa /ointment for local application.

If there is continuous burning sensation then line of treatment should be same as Pittaj Vridhadhi .

In treatment of pittaj vidradhi Acharya sushrut mention piitashamak medicine for internal as well as local application , incision and drainage on suppuration, leave it for healing with secondary intension.

Karanjadi ghrita for enhanching wound healing. Madhuchisth ghrita prepared by processing of wax (र्मोर्म,) in ghrit

with mulethi(र्मुले@ी), lodhra (लोध्र), raal ( राल ), sarjras (सज�रस) manjistha (रं्मजिजष्ठा), rakta chandana ( रक्त चन्द� ) and murva (रु्मवा�).

Name of the drugs Name of drugs Botanical name तुगाक्षीरी tugakshiri (Curcuma angustifolia). प्लक्ष Plaksha (Ficus religiosa) चन्द�, chandan (santalum album) गैरिरक Gairik Fe2O3, (ferric oxide) अरृ्मता Amrita (tenospora cardiofolia) रु्मले@ी mulethi (glycyrrhiza glabra) लोध्र lodhra (symplocos racemosa) राल raal (shorea robusta ) सज�रस sarjras रं्मजिजष्ठा manjistha   (Rubia cordifolia) रक्त चन्द� rakta chandana (sntalum album) रु्मवा� murva (Chonemorpha macrophylla)

अतितदग्ध चि�तिकत्सा अपितद�धे पिवशीणा�पि� र्मांसान्युHतृ्य शीतलार्म् | पिvयां कुया�जिद्भषक्पश्चाच्छासिलतण्डुलकण्ड�ैः| पितन्दुकीत्वक्कपालैवा� घृतयिर्मश्रैः प्रलेपयेत् | व्रणं गुडूचीपतै्रवा� छादयेदथवौदकैः | पिvयां च पि�ग्निखलां कुया�जिद्भषक् पिपNपिवसप�वत् (Su.Su. 12/25)

As per acharya Sushrut atidadagdha is similar to advanced third / fourth degree

burn , management included surgical removal of dead tissue followed by medical

treatment by above mentioned drugs as local application. Acharya sushrat indicated

to avoid bandages on affected part , the area should be covered with wet guduchi,

kamal patra etc. the rest of treatment should be same as pittaj visarp ( erysipelas) .

Gauryadi ghrita for local application.

Line of treatment Remove the dead/ burn tissue surgically

Local application of drugs mentioned in text

Covering the area with wet leaves of guduchi & lotus

Treatmentof Visarp (erysipelas )

Medical treatment to improve healing and prevent complication

Beside these dagdha condition acharya sushrut aslo mentioned some other heat injuries as dhomoghat ( person traped in fire/ asphyxia due to smoke) and ushna vat (heat stroke) .

Treatment of dhomaghat includes vaman, kaval-grah, siro-virechana followed by laghu and snigdha diet.

Current Practice of Agnikarma

Now days the agnikarma shalaka got the modification as the heat source is electricity.

This shalaka have different shape of probes for the specific use.

shalaka

Shalaka with probe probes

Current Practice of Agnikarma Now days there is list of common ailments where Agnikarma is very much effective Sciatica pain Mechanical back pain Peri-arthritis shoulder joint Frozen shoulder Osteoarthritis knee joint in early stage Cervical pain Tennis elbow Plantar fasciitis Planter Corn Viral warts

Sciatica pain

Peri-arthritis shoulder joint

Mech. Back pain

Early OA of knee joint

Plantar fasciitis / painful heal

Cervical pain

Tennis elbow

viral wart

plantar corn

Common problems with therapy

1. Patient’s consent.

2. Scar formation.

3. Recurrence

4. Needs skill to perform

5. Burn injury

Mode of Action of Agnikarma

वातादृते �ास्विस्त रुजा � पाकःपिपNादृते �ास्विस्त कफाच्च पूयः | (su.su. 17/12)

The diseases in which Agnikarma is indicated are due to vitiation of vata and kapha, so Agnikarma is considered as better therapy to pacify these dohas. Due to Ushan, Sukshma, thekshna and Ashukari guna of Agni , it pacifies vitiated vata and kapha dosha.

As per Acharya Sushrut basically anginkarm is used in two manner i.e. one for रोग उन्मूलन (diseases cure) and other for pain management.

First for the diseases cure we used is it in the assistance with surgery and for pain control we use it independently.

Mode of Action of Agnikarma

Application of Agni ( heat)

Raised Local temperature

Dilatation of local blood vessels

Increased tissue perfusion

Clearance of accumulated metabolic waste

Resolve inflammation

Reduces pain

Mode of Action of Agnikarma

Application of Agni ( heat)

Raised Local temperature

Dilatation of local blood vessels

Efficient tissue perfusion

Prompt Clearance of local inflammatory mediators

Resolve inflammation

Reduces pain

Application of Agni ( heat)

Increased local temperature

Raised local BMR

Enhances perfusion

Efficient delivery of oxygen

Ischemia and degeneration related Tissue injury healed due to better blood perfusion

Mode of Action of Agnikarma

Application of heat

Stimulation of DPI (Descending pain inhibiting mechanism)

Stimulation of CNS

Release of endogenous opioids in Pro-opiomelanocortin (POMC) cells in the arcuate nucleus &

in the brainstem( eg. Endomorphins, dynorphins etc)

Reduces pain

Mode of Action of Agnikarma

Gate control theory of pain

The gate control theory of pain asserts that non-painful input closes the "gates" to painful input, which prevents pain sensation from traveling to the central nervous system. Therefore, stimulation by non-noxious input is able to suppress pain.

Some Classical references of Agnikarma in Ayurveda

1.     त्वऽ. र्मांससिसरास्�ायुसंध्यस्थि6स्थि6तेऽत्युग्ररुजे वायु |(Sushruta samhita – sutrasthana – chapter 12, verse 10)

2.     तद्द�धा�ां रोगा�ार्मपु�र्भा�वात् र्भाेषजशस्त्रक्षारैरसाध्या�ां तत्साध्यत्वात च |(Sushruta samhita – sutrasthana – chapter 12, verse 3)

3.     स्�ेहोप�ाहाग्नि��कर्म�बJ�ोन्र्मद��ापि� च |        स्�ायुसन्ध्यस्थि6प्राप्ते कुया�त् वायावतजिन्द्रतः ||

(Sushruta samhita – chikitsasthana – chapter 4, verse 8) 

4.     अग्नि��ः क्षारादपिप शे्रष्ठस्तद�धा�ार्मसंर्भावात् |          र्भाेषजशस्त्रक्षारैश्च � सिसHा�ां प्रसाध�ात् ||

(Ashtanga hridaya – sutrashana – chapter 30, verse 40) 

5.      त्वसिच र्मांस सिसरास्�ायुसंध्यस्थि6षु स युज्यते |(Ashtanga hridaya – sutrasthana – chapter 30, verse 41)

 

6.     स्�ायुसन्धिJसिसराप्राप्ते स्�ेहदाहोप�ाह�र्म् | (Ashtanga hridaya – chikitsasthana – chapter 21, verse 22)

7.     स्�ेहोप�ाहाग्नि��कर्म�बJ�ोन्र्मद��ापि� च |        vुHे स्�ायुगते वाते कारयेत् कुशलो णिर्भाषक् ||

(Bhavaprakasha – vatavyadhi chikitsa – verse 257) 8.     कुया�त् सन्धिJगते वाते दाहोप�ाह�र्म् |

(Bhavaprakasha – vatavyadhi chikitsa – verse 259) 9.     स्�ेहोप�ाहग्नि��कर्म�बJ�ोन्र्मद��ापि� च |        स्�ायुसन्धिJसिसराप्राप्ते कुया�त् वाते पिवचक्षणः ||

(Chakradatta – vatavyadhi chikitsa – verse 9)

References of Agnikarma in Sushrut samhita Sutra sthan. Chapter 12 Chikitsa sthan 1 in 60 upakrama of vrana chiktsaa. Chikitsa sthan 6 arsha chikista Chikitsa sthan 8 bhagandar Chikitsa Chikitsa sthan 14 plihodar Chikitsa Chikitsa sthan 18 grinthi Chikitsa Chikitsa sthan 18 apchi (Lymphadenopathy Chikitsa ( at 12 angul proximal to

ankle joint on posterior side) Chikitsa sthan 18 arbud (tumour) Chikitsa Chikitsa sthan 18 galgand (neck swelling) Chikitsa Chikitsa sthan 19 antra vridhi rog (Inguinal hernia) at great toe of opposite side. Chikitsa sthan 19 slipad ( filariasis) Chikitsa sthan 20 kadar ( corn), mashak,tilkalak ( mole),

धन्यवाद Thank you

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