Sushruta Samhita Sutrasthana Chapter 12: Agnikarma Vidhi Adhyaya (Thermal Cautery)

The 12th chapter of Sutrasthana of Sushruta Samhita is named as Agnikarma Vidhi Adhyaya. This chapter deals with Thermal Cautery.

अथातोऽग्रिकर्मविधिमध्यायं  व्याख्यास्यामः ॥१॥
यथोवाच भगवान् धन्वन्तरिः ॥२॥

We will now expound the chapter by name Agnikarma vidhi – procedure of branding by fire (thermal cautery); as revealed by the venerable Dhanvantari.

Agni Karma Shrestha: Greatness of fire cautery

क्षारदग्रिर्गरीयान् कियासु व्याख्यातः तद्दग्धानां रोगाणमपुनर्भावाद्भेषजशस्त्रक्षारैरसाध्यानां तस्याध्यत्वाञ्च॥३॥

Agni means fire, Kshara means alkali. It is said that Agni is better than Ksara in action. Action of both is ‘to burn’. So, when it comes to burning from a therapeutic point, Agni is better than Kshara.

Reason – There are two main reasons for supremacy of agni over ksara –

–        The diseases which are treated and also get cured after burning by fire will not recur again.
–        The diseases which cannot get cured by administration of bhesaja – medicines, shastra – sharp surgical instruments and ksara – alkali can be effectively cured by the use of fire.

Note – When fire is used for cauterization, it is called ‘fire cauterization’ or ‘thermal cauterization’ – Agni Karma in Ayurveda. When alkali is used for cauterization, it is called ‘alkali cauterization’, Ksara Karma in Ayurveda.

Dahana Upakaranani: Equipments required for ‘cauterization by fire’

अथेमानि दहनोपकरणानि भवन्ति- तद्यथा-पिप्पल्यजाशकृद्रोदन्तशरशलाकाजाम्बवौष्ठेतरलौहा  क्षौद्रगुडस्नेहाश्च। तत्र,पिप्पल्यजाशकृद्रोदन्तशरशलाकास्त्वग्गतानां जाम्बवौष्ठेतरलौहा  मांसगतानां,क्षौद्रगुडस्नेहाः सिरास्नाय्युसन्ध्यास्थिगतानाम् ॥४॥

The equipments required for burning or fire cauterization are –

Areas of utility –

Among these,

Agni Karma Kala: Suitable time for conducting fire cautery

 तत्राग्रिकर्म सर्वर्तुषु कुर्यादन्यत्रशरन्दीष्माभ्यां तत्राप्यात्यायिकेऽग्रिकर्मसाध्ये व्याधौ  तत्प्रत्यनीकं विधिं कृत्वा॥५॥

Branding / cauterization by fire can be done in all seasons except Sarad Rtu – autumn season and Grishma Rtu – summer season. In emergency conditions, agnikarma can be done in Sharad and Grishma Rtus also, especially so in diseases which are curable only by means of agnikarma. The physician / surgeon shall pratyanika vidhi – adopt counter methods before doing the branding.

According to Master Dalhana, the pratyanika vidhi i.e. counter methods used for mitigating the effects of agnikarma include –

–        Covering the body or site where agnikarma had been done, with moist cloth
–        Use of cold foods,
–        Applying pastes which can produce cooling effect

Agnikarma vidhi: Procedure for ‘fire cauterization’ / branding

सर्वव्याधिष्वृतुषु च पिच्छिलमत्रं भुक्तवतः मूढगर्भाश्मरीभगन्दरोदरार्शोमुखरोगेष्वभुक्तवतः कर्म कुर्वीत॥६॥

Before conducting agnikarma procedure, the patient should be given with pichchila bhojana i.e. foods which are slimy. The foods shall also be cold in potency and soft in texture. This rule is applicable for all diseases (eligible for agnikarma) and all seasons.

Contrary to this, agnikarma should be done for the patient who has not consumed food i.e. on empty stomach in the below mentioned diseases –

–        Mudha Garbha – obstructed fetus
–        Ashmari – urinary calculus
–        Bhagandara – fistula in anal region
–        Udara – enlargement of abdomen
–        Arsha – piles / hemorrhoides
–        Mukha Roga – Diseases of the mouth

Bheda: Kinds of branding / fire cauterization

तत्र द्विविधमग्रिकर्माहुरेके-त्वग्दग्धं,मांसदग्धं चम् इह तु सिरास्नायुसन्ध्यस्थिष्वपि न प्रतिषिद्धोऽग्रिः ॥७॥

Some authorities have classified agnikarma into two types i.e.

1.    Tvak Dagdha – burning of the skin and
2.    Mamsa Dagha – burning of the muscles

But according to the Dhanwantari school of surgery, conducting agnikarma on sira – veins, snayu – ligaments, sandhi – bony joints, asthi – bones is also not prohibited. Therefore, agnikarma is a procedure not just limited to be conducted on skin and mamsa but can also be done over the veins, ligaments, bony joints and bones.

Signs of burning of skin, muscles, veins, tendons, joints and bones using fire cautery

तत्र,शब्दप्रादुर्भावो दुर्गन्धता त्वक्संकोचश्च त्वग्दग्धे,कपोतवर्णताऽल्पश्वयथ्य्वेदना शुष्कसंकुचितव्रणता च मांसदग्धे,कृष्णोन्नतव्रणता स्त्रावसन्निरोधश्च सिरास्नायुदग्धे रुक्षारुणता कर्कशस्थिरव्रणता च सान्ध्यस्थिदग्धे ॥८॥

Dahana pradesa: Sites of Branding

 तत्र शिरोरोगाधिमन्थयोर्भूललाटशङ्खप्रदेशेषु दहेत्,वर्त्मरोगेष्वार्द्रालक्तकप्रतिच्छ्न्नांदृष्टिं कृत्वा वर्त्मरोमकूपान् ।९॥

In diseases of the eyelids, branding should be done on the follicles of hairs (eyes lashes) after covering the area of vision (pupil and cornea) with a pad of wet cloth.

Other indications of Agnikarma

त्वङ्मांससिस्नायुसन्ध्यस्थिस्थितेऽत्युग्ररुजि वायावुच्छ्रतकठिनसुप्तमांस व्रणेग्रन्थ्यर्शोऽर्बुदभगन्दरापचीश्लीपदचर्मकीलतिलकालकान्त्रवृद्धिसन्धिसिराच्छेदनादिषु नाडीशोणितातिप्रवृत्तिषु चाग्रिकर्म कुर्यात् ॥१०॥

Burning by fire (branding) should also be done in the below mentioned conditions –

–        Ati ugra ruja – very severe pain in the skin, muscles, veins, ligaments, joints and bones caused by aggravated vata
–        Uchrita kathina supta mamsa – muscular outgrowths are found in the ulcer / wound. These outgrowths have become hard and numb.
–        Granthi – cysts / tumors
–        Arsha – hemorrhoids
–        Arbuda – malignant tumor
–        Bhagandara – fistula-in-ano
–        Apachi – glandular swelling in the neck
–        Shlipada – filariasis
–        Charmakila – warts on the skin
–        Tilakalaka – moles
–        Antra vriddhi – hernia
–        Sandhi chedana – tearing pain in the joints
–        Sira chedana – tearing of veins
–        Nadi vrana – sinus ulcers
–        Shonita ati pravritti – excessive bleeding (profuse hemorrhages)

Different patterns of branding  

तत्र वलय-बिन्दु-विलेखा-प्रतिसारणानीति दहनविशेषाः ॥११॥ 
भवति चात्र-
रोगस्य संस्थानमवेक्ष्य सम्यङ्नरस्य मर्माणि बलाबलं च |
व्याधिं तथर्तुं च समीक्ष्य सम्यक् ततोऽव्यवस्येद्भिषगग्निकर्म ||१२||

Below tabulated are the different shapes or patterns of fire cautery –

Points to consider before conducting agni karma –

The physician should conduct agnikarma after carefully considering the below mentioned points –

–        the gravity of symptoms of the diseases,
–        the vital spots,
–        strength of the patient,
–        disease and seasons

Follow up of fire cauterization

ततत्र सम्यग्दग्धे मधुसर्पिर्भ्यामभ्यङ्गः ॥१३॥

The area which has been burnt by the fire shall be anointed with a mixture of ghee and honey once the agnikarma has been conducted in a smooth and proper way.

Agni Karma anarha: Persons ineligible for agnikarma / contraindication of branding

अथेमानग्रिना परिहरेत्- पित्तप्रकृतिमन्तः शोणितं भिन्नकोष्ठमनुद्धतशल्यं दुर्बलं बालं वृद्धं भीरुमनेकव्रणपीडितमस्वेद्यांंश्चेति ॥१४॥

Agnikarma should be avoided in the below mentioned conditions / persons –

–        pitta prakriti – pitta constitution persons
–        antah shonitam – those in whom the blood has been accumulated in the abdomen or those having bleeding disorders,
–        bhinna koshta – diarrhea / rupture of abdominal organs
–        anuddhata shalya – persons in whom the foreign body has not been removed,
–        durbalam – those debilitated
–        balam – children
–        vriddham – aged persons
–        bhiru – those fearful
–        aneka vrana pidita – those suffering from multiple wounds / ulcers,
–        asvedyah – those unfit / not eligible for sudation therapy

 Anyatha Dagdha: Burning other than by fire cauterization / banding

अत ऊर्ध्वमितरथादग्धलक्षणं वक्ष्यामः । तत्र स्निग्धं रुक्षं वाऽऽ(चा)श्रित्यद्रव्यमग्रिर्दहति: अग्रिसंतप्तो हि स्नेहः सूक्ष्मसिरानुसारित्वात्त्वगादीननुप्रविश्याशु दहति;तस्मात् स्नहेदधेऽधिकारुजो भवन्ति॥१५॥

Going ahead we will describe the features of itara dagdha i.e. other kinds of burning (for the treatments of diseases),

–        The heat (derived from agni or fire) resides in the heated substances like fats and oils – which are unctuous in nature or some non-unctuous (dry) substances, (i.e. heat of fire in fire cautery can be given through unctuous or dry substances which are heated, which act as carriers of fire or heat)
–        When heated, the Sneha i.e. fatty substances become capable of traveling through the minutest veins, spaces and pores of the body. They gain entry into the skin and other tissues very quickly when administered and cause burning therein. Therefore, agnikarma done with Sneha or fatty substances are severely painful.

Dagdha Bheda: Kinds of burns

तत्र प्लुष्टं दुर्दग्धं सम्यग्दग्धमतिदग्धं चेति चतुर्विधमग्रिदग्धम् । तत्र यद्विवर्णं प्लुष्यतेऽतिमात्रं तत प्लुष्टं;यत्रोत्तिष्ठन्ति स्फोटास्तीव्राश्चोषदाहरागपाहवेदनाश्चिराचचोपशाम्यन्ति तद्दुर्दग्धं;सम्यग्दग्धमनवगाढं तालवर्णं सुसंस्थितं पुर्वलक्षणयुउक्तं च;अतिदग्धे मांसावलम्बनं गात्रविश्लेषः सिरास्नायुसन्ध्यस्थिव्यापादनमतिमात्रं ज्वरदाहपिपासामुर्च्छाश्चोपद्रवा,भवन्ति,व्रणश्चास्य,चिरेन रोहति,रुढश्च विवर्णो भवति। तदेतञ्चतुर्विधमग्रिदग्धलक्षणमात्मकर्मप्रसाधकं भवति ॥१६॥

Agni dagdha i.e. burns caused by fire are of four kinds, they are –

A thorough knowledge of the features of these four kinds of ‘degrees of burns’ i.e. agni dagdha will help the physician / surgeon to perform these procedures confidently and attain success while treating the patients.

Aggravation of blood and pitta by the burns

अग्रिना कोपितं रक्तं भृशं जन्तो प्रकृप्यति।
ततस्तेनैव वेतेन पित्तमस्याभ्युदीर्यते ॥१७॥
तुल्यवीर्ये उभे द्येते रसते द्रव्यतस्तथा ।
तेनास्य वेदनास्तीव्राः प्रकृत्या च विदाद्यते ॥१८॥
स्फोटाः शीघ्रं प्रजायन्ते ज्वरस्तृष्णा च बाधते ।

When fire cautery is done, the blood gets aggravated by the effect of fire. This blood further undergoes aggravation to greater levels in the body of the person who has undergone agnikarma. Rakta and pitta are closely related by ahsraya ashrayi bhava i.e. residence (blood) – resident (pitta) relationship. Also, both blood and pitta are similar in potency, taste and substance. When the blood gets aggravated due to agnikarma, the pitta too gets aggravated at the same pace due to the aggravation and intensity of the blood. Due to simultaneous aggravation of both blood and pitta there naturally occurs severe pain and burning sensation. Blisters / vesicles also develop quickly and there is also a severe increase of fever and thirst.

Dagdha Chikista: Treatment of Burns

Plushta Dagdha Treatment

दग्धस्योपशमार्थाय चिकित्सा संप्रवक्षते॥१९॥
प्लुष्टस्याग्रिप्रतपनं कार्यमुष्णं तथौषधम् ।
शरीरेस्विन्नभूयिष्टे स्विन्नं भवति शोणितम् ॥२०॥
प्रकृत्या ह्युदकं शीतं स्कन्दयत्यतिशोणितम् ।
तस्मात् सुखयति ह्युष्णं नतु शीतं कथंचन ॥२१॥

Now, the treatment to mitigate the sufferings of persons who are suffering from burns shall be explained –

Treatment of Plushta Dagdha (burns of the first degree)

Firstly, to increase the body temperature or to warm up the body, heat from fire should be provided to the burnt area.

Similarly, medicines having hot potency shall be administered externally (application) as well as internally (oral consumption).

Reason – The body starts sweating due to the effect of burns. This is because the body temperature would increase due to burns. Consequently, the blood too starts getting liquified in the body. The logic will be to administer cold comforts and medicines. But in this condition if cold comforts are given or if cold water etc. is sprinkled on burns, the cold water would thicken the blood and cause coagulation owing to its cold potency. Therefore, only hot water should be used to sprinkle or irrigate the ulcers or wounds caused by burns. Only hot water shall be used for drinking purposes and only hot comforts shall be used. So, cold water or cold things should never be used for this purpose.

Treatment of Durdagdha Treatment

शीतामुष्णां च दुर्दग्धे क्रियां कुर्याद्भिषक पुनः ।
घृतालेपानसेकांस्तु शीतानेवास्य कारयेत् ॥२२॥

Durdagdha – burns of the second degree

In Durdagdha, the physician should administer both warm and cold therapies or comforts. But ghee or anointments should be used cold. Similarly, herbs, ghee, and liquids having cold potency or prepared cold shall be used for bathing / showering the body.

Treatment of Samyak Dagdha

सम्यग्दग्धे तुगाक्षीरीप्लक्षचन्दनगैरिकैः ।
सामृतैः सर्पिषा स्निग्धैरालेपं कारयेद्भिषक ॥२३॥
ग्राम्यानूपौदकैश्चैनं पिष्टैमौसैः प्रलेपयेत् ।
पित्तविद्रधिवच्चैनं संततोष्माणमाचरेत् ॥२४॥

Samyak Dagdha – burns of third degree

Tugakshiryadi Kalka – In Samyak dagdha condition, smooth paste of Tugakshiri, Plaksha, Chandana, Gairika and Amrita prepared by grinding them on a clean stone slab or in a mortar should be applied over the body after mixing it with ghee. Alternatively, ghee prepared with the same herbs shall be applied over the body.

Also, paste of meat of domestic animals, marshy regions and water shall be applied over the body.

Treatment of Pitta Vidradhi – Treatment should be done on the lines of treating ‘pittaja vidradhi’ i.e. abscess caused by predominant vitiation of pitta should be administered if there is constant burning sensation in the burnt area or the whole body.

Treatment of Atidagdha

अतिदग्धे विशीर्णानि मांसान्युद्धत्य शीतलाम् ।
क्रियां कुर्याद्भिषक् पश्चाच्छालितण्डुलकण्डनैः ॥२५॥
तिन्दुकीत्वक्कपालैर्वा घृतमिश्रैः प्रलेपयेत् ।
व्रणं गुडूचीपतैर्वा छादयेदथवौदकैः ॥२६॥
क्रियां च निखिलां कुर्याद्भिषेक पित्तविसर्पवत् ।

Atidagdha – burn of the fourth degree

Firstly, in case of atidagdha, the torn and loosely hanging muscle should be cut and removed.

After this, cold therapies should be done. All cold comforts should be given.

Following this, powder of broken rice or decoction or bark of tinduki should be applied after mixing it with ghee.

Wounds or ulcers caused by burns should be covered with leaves of Guduchi – Tinospora cordifolia or leaves of aquatic leaves like lotus etc.

All other treatments should be done on the lines of treating ‘pittaja visarpa’ – herpes / erysipelas of pitta origin.

Maducchistadi Ghrita

मधुच्छिष्टं समधुकं रोध्रं सर्जरसं तथा॥२७॥
मञ्जिष्टां मूर्वा पिष्ठ्वा संर्पिर्विपाचयेत् ।
सर्वेषामग्रिदग्धानामेतद्रोपणमुत्तमम् ॥२८॥
स्नेहदग्धे क्रियां रुक्षां विशेषेणावचारयेत् ।

The below mentioned herbs shall be macerated and made into paste –

–        Madhucchista,
–        Madhuka,
–        Rodhra,
–        Sarjarasa,
–        Manjista,
–        Candana and
–        Murva

This Madhuchistadi Kalka (paste) should be used to process and prepare ghee. This is the best and most praised ghee for healing all kinds of burnt wounds.

Dry treatments should be done especially in case of burns caused by hot fats (ghee, oil etc.).

Dhumopahata Lakshana: Symptoms of suffocation by smoke

अत ऊर्ध्वं प्रवक्ष्यामि धूमोपहतलक्षणम्॥२९॥
श्वसिति क्षौति चात्यर्थमत्याधमति कासते।
चक्षुषोः परिदाहश्च रागश्चैवोपजायते ॥३०॥
सधूमकं निःश्वसिति घ्रेयमन्यन्न वेति च ।
तथैवच रसान् सर्वान् श्रूतिश्चास्योपहन्यते ॥३१॥
तृष्णादाहज्वरयुतः सीदत्यथ च मूर्च्छति ।
धूमोपहत इत्येषः,श्रृणु  तस्य चिकित्सितम् ॥३२॥
सर्पिरिक्षुरसं द्राक्षां पयो वा शर्कराम्बु वा
मधुराम्लौ रसौ वाऽपि वमनाय प्रदापयेत् ॥३३॥
वमतः  कोष्ठशुद्धिः स्याद्धूमगन्धश्च नश्यति ।
विधिनाऽनेन शाम्यन्ति सदनक्षवथुज्वराः ॥ ३४॥
दाहमूर्च्छातुडाध्मानश्र्वासकासाश्च दारुणाः ।
मधुरैर्लवणाल्मैश्व कटुकैः कवलग्रहैः ॥३५॥
सम्यग्गृह्णातीन्द्रियार्थान् मनश्चास्य प्रसीदति।
शिरोविरेचनं चास्मै दद्याद्योगेन शास्त्रवित् ॥३६॥
दृष्टिर्विशुध्यते चास्य शिरोग्रीवं च देहिनः ।
अविदाहि लघु स्निग्धमाहारं चास्य कल्पयेत् ॥३७॥

Now, the symptoms of dhumopahata – the person troubled by suffocation by smoke shall be described. They are as below mentioned –

–        Shvasa – dyspnea, exaggerated breathing / difficulty in breathing / shortness of breath
–        Ati kshavatu – continued and repeated sneezing,
–        Adhmana – distension of abdomen / flatulence and
–        Kasa – cough
–        Chakshu paridaha – burning sensation in the eyes
–        Chakshu Raga – redness in the eyes
–        Sa dhuma nishvasa – exhales smoke or presence of smell of smoke in the breath
–        Ghreyam any ana vetti – perceives smell of only smoke and does not perceive the smell of anything else
–        Rasan sarvan upahanyate – loss of perception of all tastes
–        Shrutischa upahanyate – impairment of hearing capacity (loss of sound perception)
–        Trishna – thirst
–        Daha – burning sensation
–        Jwara – fever
–        Sidati – debility / weakness
–        Murchati – fainting

Now the treatment of dhumopahata shall be explained, listen to it.  

Treatment of Dhumopahata

Vamana (emesis) – In dhumopahata, vamana – emesis therapy should be administered at the beginning. Ghee, sugarcane juice, juice of raisins, milk, sugared water or things of sweet or sour tastes shall be used for the purpose of inducing vamana. With vamana, koshta Shuddhi i.e. cleansing of gut and chest will be achieved and the smell of smoke will also disappear. Debility, sneezing and fever too would get pacified due to the effect of vamana. The person will also be relieved from burning sensation, fainting, thirst, distension of abdomen / flatulence and severe dyspnea and cough.

Kavala (mouth gargles) – Herbs with sweet, salt, sour and pungent tastes shall be used to prepare decoctions which shall be used as mouth gargles. By regularly gargling these decoctions, the person will be able to perceive objects of all sense organs. It would also bring about clarity of mind.

Shiro Virechana (errhines, nasal medication to cause purging of head) – Purging errhines shall be skillfully administered by the physician having good knowledge of therapies, after having administered vamana effectively. This shall be done adhering to the procedures explained in Ayurveda. This will bring about clarity of sight (vision) and will also cleanse his head and neck.

After this, foods which are light and easily digestible, unctuous and which do not cause burning sensation should be given to the patient.

Atapadi Dagdha: Sunstroke etc.

उष्णवातातपैर्दग्धेशीतः कार्यो विधिः सदा ।
शितवर्षानिलिलैग्धे स्निग्धमुष्णं च शस्यते ॥३८॥
तथाऽतितेजसा द्ग्धे सिद्धिर्नास्ति कर्थचन ॥
इन्द्रवज्राग्रिदग्धेऽपि जीपति प्रतिकारयेत् ॥
स्नेहाभ्यङ्गपरिषेकैःप्रदेहैश्च तथा भिषक् ॥३९॥

Shita Karya Vidhi – All cold treatments should be done and cold comforts administered always in case of burns caused by hot breeze and severe heat of the sun (sunstroke).

Singdha Ushna Vidhi – Treatments or comforts which are unctuous and hot will be beneficial for those afflicted by severe cold, rain storm and cold breeze and should be skillfully administered.

In case of assault by severe lightning or thunder any type of treatment will not yield success. If by chance or luck, if any person has survived these assaults and is found alive, the physician shall treat him with unctuous therapies, oil massage, oil bath (showering) and application of warm and thick paste of herbs.

इति श्रीशुश्रुतसंहितायां सूत्रस्थानेऽग्रिकर्मविधिर्नाम द्वादशोऽध्यायः ॥१२॥

Thus ends the Twelfth chapter by name Agnikarma Vidhi- in Sutra Sthana of Susruta Samhita.