Book Review

1. Introduction

Viṣacikitsā or Ayurvedic toxicology was once a branch practiced effectively by Ayurvedic physicians, now in peril. Due to sociolegal reasons, acute snake poisoning cases have become near inaccessible to Ayurvedic practitioners. Hence, Ayurvedic toxicology practice currently focuses on minor to moderate poisonings, and allergic and autoimmune disorders [1,2]. Kerala was a region of active viṣacikitsā practice [3]. Multiple texts on Viṣacikitsā showcasing modified forms of classical Ayurveda prevailed in Kerala. Though limited, there are still Viṣavaidyas who treat snakebites [4]. But the awareness regarding these centers was observed only among 53.85% of the Ayurvedic community studied [5].

Jyotsnikā is one among the oldest Keralan works on toxicology. It was widely taught and practiced in Kerala. After learning the text Aṣṭāṅga Hṛdaya for general practice, scholars who intended to specialize in toxicology learnt Jyotsnikā. Later, texts like Prayogasamuccaya, Kriyākaumudi, and Viṣacandrikā were also referred [6]. Jyotsnikā was distinct from its contemporaneous texts due to its comprehensive, practicable, and transdisciplinary nature. It was a complete handbook for a toxicologist including relevant lifestyle, ethics, etiquette, nosology, symptoms, prognostication, therapies (medicines, procedures, hymns), and pharmaceutics. Many medicines used in the text were easily available in most gardens and kitchens, making its practice feasible (e.g.: Moringa oleifera, Boerhavia diffusa, Curcuma longa, Tabernaemontana divaricata). It incorporated and applied concepts from Yoga (e.g.: Iḍa and Piṅgala nāḍīs, represented by the exhaled stream of air), Tantra (e.g.: Bhūta predominance of letters and their role in prognosis), and Jyotiṣa (e.g.: combined influence of the birth star of the patient and time of bite on prognosis), making it a book of interest.

2. Author, region, period and school

Little information is available regarding the author of Jyotsnikā. The author introduces himself as Narayanan and says that he is the disciple of two Gurus with the same name, “Vasudevan”. Karatt Narayanan Namboothiri, a famous Viṣa Vaidya is considered the author of Jyotsnikā by historians and scholars. He was the disciple of two Gurus (who were father and son, from the Kāśyapa clan), sharing the same name, “Vāsudevan” [7].

The book has been written in a combination of Sanskrit and Malayalam, but not Manipravāḷaṃ. The text is said to be influenced by multiple works like Uḍvīśaṃ, Lakṣaṇāmṛtaṃ (Viṣa)nārāyaṇīyaṃ, Haramekhalā, Utpalaṃ, Kālavañcanaṃ (and according to some authors, Sārasaṅgrahaṃ). These texts are available in dilapidated forms.

3. Uniqueness of the text

Post-classical Ayurvedic literature were predominantly practice oriented. They focused on two areas: knowing the disease from all dimensions (vyādhitatva) and managing it (bheṣajatatva). Jyotsnikā was novel in both these aspects. But the post-classical single drugs and formulations are found in multiple manuscripts of same or unknown period. Hence, many of them cannot be attributed to a single text. The emphasis of this review would be on the contributions of Jyotsnikā in vyādhitatva. The text contains 21 chapters, each having specific areas of interest (Table 1).

Table 1.

Chapters and contents of Jyotsnikā.

No.	Chapter name	Contents
1.	Gurugaṇeśābhivandanaṃ	Fundamentals and ethics of toxicology practice
2.	Dūtalakṣaṇādikaṃ	Omens and their role in prognosis
3.	Viṣādilakṣaṇaṃ	Signs of various bites
4.	Cikitsārambhaṃ	Immediate remedial measures
5.	Darvīkara Viṣacikitsā	Management of ‘Darvīkara’ snake bite
6.	Maṇḍalī Viṣacikitsā	Management of ‘Maṇḍali’ snake bite
7.	Rājila Viṣacikitsā	Management of ‘Rājīmanta’ snake bite
8.	Cikitsākramaṃ	Procedures and diet in detail
9.	Lehyatailādikramaṃ	Electuaries and oils and used in management
10.	Sudhākalādinirūpaṇaṃ	Understanding Amṛtakalā and Viṣakalā
11.	Mūṣika Viṣacikitsā	Management of rat bite
12.	Vṛścikādi Viṣapratiṣedha	Management of scorpion and other venomous animal bites
13.	Sthāvara Viṣacikitsā	Poison from inanimate sources and their management
14.	Paśu Viṣacikitsā	Management of poisoning in animals
15.	Sarva Viṣacikitsā	Formulations and procedures universally applicable in toxicology
16.	Sarvamahā viṣacikitsā	Special preparations
17.	Nāgotpattikramaṃ	Origin and classification of snakes
18.	Sarpalakṣaṇādikaṃ	Peculiarities of each snake and causes of their bite
19.	Mantrasvarūpādikramaṃ	Introduction to and instructions regarding the usage of Mantras
20.	Mantraprayogaṃ	Usage of Mantras
21.	Vaidyapāramparyaṃ	Details of the author and his lineage

3.1. Symptomatology

Jyotsnikā has simplified the clinical features of each viṣa and the signs of viṣa located in each tissue from the classical triad. Its clinical methods lie interspersed with other streams of knowledge like astrology and Yoga.

3.1.1. Viṣaghaṭikā and amṛtaghaṭikā (The ambrosial and toxic phases of the clock)

A day is divided into 60 nāḍikās (1 nāḍīkā≈24 min) starting from the time of sunrise that day. Of them, four nāḍikās indicate good prognosis for a particular birth star (when afflicted with poison), and they are called Amṛtaghaṭikās. Similarly, four nāḍikās are reflective of poor prognosis, and are called Viṣaghaṭikās. For e.g., for a person of Kārtika birth star, the 54th to 58th nāḍikās are Amṛtaghaṭikās and 30th to 34th nāḍikās are Viṣaghaṭikās. If he or she gets bitten at the former, recovery is more likely, and vice versa. This is an astrological concept. This complexity in nāḍikā calculation arises from the differences in the relative zodiac (rāśī) positions of planets, that is in turn based on the birth star of individuals. The days of the week, the ‘tithi’, and the status of the planets are indicative of either good or bad prognoses based on the birth star of the individual.

3.1.2. Dūtalakṣaṇa (omens associated with messenger)

Prognosis indicated by the messenger and omen have been mentioned in the earlier texts too. The place where the incident has taken place, the time of bite, etc. Also influence the outcome. The relative position of the messenger (in terms of Aṣṭadik or the eight directions) and Vaidya is a tool that was used to understand which organism had bitten the individual.

3.1.3. Śara parīkṣā (airstream based prognostication)

‘Śara’ denotes the stream of air exhaled. Its force varies between nostrils. The four fingers of the right hand are held across the breath. The side on which the stream of breath is more felt is considered as the side of śara. The śara of the Vaidya and the position of Dūta are compared to arrive at speculations regarding the venomous organism, the site of bite, intensity of the venom, and the prognosis. The śara concept is further elucidated in astrology texts like Praśnamārga. Practitioners of astrology and toxicology are advised to practice Prāṇāyāma in the morning and ascertain the śara of oneself, probably to avoid bias while using it for prognostication. The site of bite is guessed by considering the month, the phase of the moon, and gender of the victim.

3.1.4. Akṣara parīkṣā (prognostication based on the words of messenger)

The first sentence spoken by messenger and its first letter give significant hints regarding the case. The total number of letters in the sentence are divided by three. If the remainder is one, prognosis is considered good. If the remainder is two, then it is curable with difficulty. If there is no remainder, mortality is likely. Division of the initial number by eight reveals the animal that has bitten. The vowel of the first letter spoken indicates the number of fangs. E.g.: If the patient speaks Ka as the first letter, then the vowel is ‘a’ and number of fangs is one. Similarly, it is two in ‘i’, three for ‘u’, and four for ‘e’. The alphabets have been divided based on Bhūta predominance too. Of them, ‘aqueous’ (jala-predominant) letters indicate good prognosis. They are ā, ī, ū, gh, jh, ḍh, dh, bh, v, and ḷ.

This technique seems to be adopted from Tantra vidyā. The texts Tantrasāra (Tantrasāra 3/1) [8] and Tantrāloka (Tantrāloka 3/175) [9] describe the cosmological origin of letters. The three initial letters in nature, a, i, and u are reflections (parāmarśas) of three principal active forces: supremacy (anuttara), will (icchā), and initiation (unmeṣa). They represent enlightenment and are solar in nature. They have their counterparts characterized by rest, and predominant in lunar qualities. They are contentment (ānanda), control (īśana), and waves (ūrmi), reflected as ā, ī, and ū. These six letters not only give rise to the remaining letters, but also represent the whole abstract universe (śakti prapañca). Praśnamārga (Praśnamārga 2/107) [10] uses this concept in prognosticating the outcomes of events (for which an astrologer has been consulted). The five consonants of each varga (‘ka’ varga, ‘ca’ varga, etc.) are considered predominant in air, fire, earth, water, and sky respectively. The vowels a, i, u, ṛ, lṛ, aṃ, and aḥ represent earth, and remaining indicate predominance of water (jala). The conversations starting with letters predominant in jala are indicative of good prognosis, whereas as earth-predominant letters and others indicate moderate and poor prognosis respectively.

3.1.5. Līnajīvan (latent life)

If the patient loses consciousness immediately after being bitten, the spread of toxin over the body and further pathogenesis gets inhibited. Hence, the physician needs to understand that this unconsciousness indicates the presence of life in latent form, and not death. The confirmatory signs of death are also mentioned following this, similar to those in classics: The involuntary passing of stool and urine, open or dilated orifices, absence of horripilation on sprinkling cold water, absence of bleeding on making an incision over forehead, and absence of weal formation on beating with a stick.

3.1.6. Amṛtakalā and viṣakalā (ambrosial and toxic meridian)

The biometeorological relation between the human body and moon has been a subject of curiosity from Vedic period. A similar effect of moon has been made use of in Viṣacikitsā too. Starting from the first day of the ascending lunar phase, an imaginary point or area called Amṛtakalā starts travelling upwards from the greater toe of the right side of male and left side of female. It ascends in the order greater toe → foot → ankle → knee → genitals → umbilicus → heart → breast → throat → nose → ear → eye → midline of eyebrows → forehead → vertex. It reaches vertex by the full moon and thereafter it starts descending through the opposite side, in the reverse order. On the full moon day, it ends up in the greater toe of the left leg of the male and right leg of the female.

The utilities of these sites are both prognostic and therapeutic. When the toxin is over the Amṛtakalā, it is of better prognosis and vice versa. Tactile stimulation of these spots or meditation focusing on the same sustains health and expedites recovery. This method is an example for the improvisation and incorporation of techniques for Yoga into Ayurveda.

3.1.7. Pāvaka parīkṣā (prognostication by fire-testing of medicines)

The formulations used for viṣacikitsā, especially ghee and oils are poured into the fire in which they were cooked. The flame color reflects prognosis of the disease (The relevance of this concept is minimal today, as most medicines are ready-to-use).

3.1.8. Other poisonings

The symptoms of cattle getting poisoned have been mentioned. The mentioning that the milk of a poisoned cow is as good as poison, is of current significance. Among viṣa symptoms, high importance has been given to rat venom and its treatment. Among poisoning by other animals, scorpion, spider, dog, fox, horse, monkey, human, wasp, skinks, etc. have been mentioned briefly. Gara Viṣa, Dūṣī Viṣa, etc. are not seen in the available versions of the text.

3.2. Treatment

The general treatment guidelines for treatment resemble that of older texts. Specific management guidelines for toxin situated in each tissue are given (Table 2).

Table 2.

Toxin, its substratum and treatment.

Substratum of the toxin	Treatment
At the site of bite	First aid, Mantra, Auṣadha
Tvak – Rakta – Māmsa	Herb blowing
Medas – Asthi	Divyauṣadhās internally, externally
Majja – Śukra	Nasya, Añjana, etc.
Chronic	Medicated oils and ghee

The management of toxin at a substratum must include that of the next one too (for preventing the ascent of poison). The first aid for snakebite is similar to that in Aṣṭāṅga Hṛdaya.

3.2.1. Ūttu cikitsā (herb blowing)

Ūttu cikitsā is as an improvised form of dhmāna nasya or nasal powder administration. It is the procedure wherein the patient is surrounded by three assistants who chew the indicated herbs in their mouth and blow air to the vertex and both the ears of the patient from three directions. Air is blown 150 times. The herbs in mouth are to be spit out and fresh ones chewed on salivation. Another simplified method is where the medicine is blown by an assistant and the eyes, nose and ears of the patient are kept closed. In this method, air is blown 360 times. Ūttu is effective when initial three dhatus, i.e., Twak, Rakta, Māmsa are affected. One of the most popular formulations used for the therapy is Viśvādi yoga, containing Zingiber officinale, Tragia involucrata, Piper nigrum, and Aristolochia indica.

3.2.2. ‘Pañcakarma’

In viṣacikitsā, there is a separate set of procedures that are termed Pacakarma. They are respectively nasal medication, collyrium, herbal bath, oral fluids, and anointments (nasya, añjana, snāna, pāna, and ālepa). They are indicated once the poison ascends from the site of bite. Among them, Nasya and Añjana are specially indicated in poisons located at majjā and sukra. Besides them, dhārā and raktamokṣaṇa are also elaborated.

3.2.3. Hymns

Mantras were integral parts of viṣacikitsā even in the period of Caraka. They existed in both the Aryan and Dravidian traditions of viṣacikitsā. Sanskrit hymns were used by Aryans whereas in the Dravidian style, they were folk in accent. These hymns were considered secret and were valid and effective only when learned from a preceptor or Guru. Jyotsnikā has a separate chapter on Mantras alone. They are classified into nourishing (poṣaka), favoring (bandhuka), serving (sevaka), and attacking (ghātaka) based on the relation between their number of letters and planetary positions of the practitioner. The first two are considered apt for practice, the third one moderate, and the last one is to be avoided (which differ as per individual) (Jyotsnikā 20/17–20) The mantras also vary based on the purpose for which they are used, like those which fulfils the desires of the practitioner, those which destroys his adversaries, etc. Hymns that contain maledictions and imprecations are avoided as they may be harmful to both the adversary and the practitioner (Agnipurāṇa 293/14–15) Hence, just like being highly effective, Mantras could also prove detrimental to the patient and practitioner if used indecorously (based on the Mantra practiced, the error in pronunciation, and fault in decorum) [11]. Hence, some editions of Jyotsnikā have omitted this chapter. The diet and lifestyle of a mantra practitioner has been explained in Agnipurāṇa (Agnipurāṇa 293/18–19) [12]. It is not found in Jyotsnikā.

3.2.4. Materia medica

Many medicines of Jyotsnikā are still practice as they are convenient to avail and prepare, especially those in snakebite management (Table 3).

Table 3.

Types of snake and medications for their poisoning.

Snake	Examples for medication
Darvīkara (Vāta):	•Trikaṭu + Kāñjika/water •Withania somnifera + water/human urine •Roots of Tabernaemontana divaricata/Pongamia pinnata/Tinospora cordifolia/Capparis sepiaria + Piper nigrum
Maṇḍalī (Pitta):	•Indigofera tinctoria, Stereospermum suaveolens, Santalum album, Pongamia pinnata, etc. are advised for internal as well as external applications. •Śigrūpunarnavādi lepa, which is frequently used by the physicians of Kerala in treating swellings have been mentioned under this heading.
Rājīmanta (Kapha):	•Trikaṭu + warm water •Pippali + Saindhava + warm water •White variety of Tephrosia purpurea

3.2.5. Diet

Oryza sativa, Paspalum scrobiculatum, Setaria italica, etc. Are the grains recommended in poisoning. Amaranthus polygonoides, Platostoma hispidum, Centella asiatica, Acmella calva, Pergularia daemia, Holostemma ada-kodien (herbs) and Benincasa hispida, Momordica charantia, Trichosanthes cucumerina, Cucumis sativus (vegetables) are also advised. Meats of mongoose, peacock and cuckoo are most conducive whereas that of deer, tortoise, porcupine, etc. are moderately recommended. Fish other than pickerel are to be avoided because they cause stagnation and increase of toxin inside the body. Fish cooked without its spikes is strictly contraindicated in poisoning.

3.2.6. Preparations

There is low commercial availability of formulations in Jyotsnikā. Most available formulations are those requoted from other texts like Śatadhauta ghṛta and Vilvādi guṭikā. Unique formulations like Śigrupunarnavādi lepa and Nīlīdaḷādi ghṛta are in the market, whereas formulations like Garuḍāñjana [13] Taruṇabhāskara guṭikā, and Mṛtyuñjaya guṭikā have been documented to be in use of experienced Viṣavaidyās [6].

4. Status in press

The latest printed version of the book (Malayalam) has been edited and commented by Dr. Rajani Nair and published by Kerala State Institute of Languages (2017). This book titled “Viṣajyotsnikā: Pāṭhavuṃ paṭhanavuṃ” is a detailed study regarding Jyotsnikā as well as the traditional lineage of viṣacikitsā in Kerala [7]. The version edited by K. Parameswara Menon (1927) is available as e-book online (Link in the reference) [14]. The second edition of the same was digitized in August 2009 by U M.T. Brahmadathan Namboodiri cooperated with Prof. Tsutomu Yamashita of Kyoto University (Japan) and has been made available online in IAST script (International Alphabet of Sanskrit Transliteration) [15].

4.1. Translation into other languages

The English translation of the book has been done by Dr. C. M. Sreekrishnan (toxicologist from Kerala), published by Kottakkal Arya Vaidya Sala in the name Viṣavaidyajyotsnikā. No translations are available in other languages.

5. Strengths, weaknesses, and future scope

5.1. Strengths

5.1.1. Principles

Several principles of Jyotsnikā remain valid and relevant till date. For instance, presence of moonlight improves the prognosis of snakebites as per Jyotsnikā. The activity of adult prairie rattlesnakes (Crotalus viridis) was observed to decrease with the increase in moonlight (likely a predator-avoidance strategy) [16].

5.1.2. Practices

The book addresses most toxins and provides management strategies both for hospitals (like Mṛtyuñjaya agada, Garuḍāñjana) and resource-limited settings (nasya with Lagenaria siceraria, a documented antidote [17] and asafetida powder).

Inanimate poisons and their management have been covered comprehensively. It recommends Indigofera tinctoria as a universal antidote for all sthāvara viṣas. Home-based antidotes for various intoxications, hypersensitivities, and indigestions are also given (these antidotes are seen in other texts of Kerala as well) (Table 4).

Table 4.

Home-based antidotes for common sthāvara viṣas.

Agent causing reactions	Antidotes
Intoxications and hypersensitivities
Aconite	Nirviṣī (Ophiorrhiza mungos, Curcuma augustifolia)
Cannabis sativa	Coccinia indica fruit
Mercury	Benincasa hispida
Papaver somniferum	Coccinia indica root, leaf
Strychnine	Abrus precatorius tender leaves
Tobacco	Coconut milk
Indigestions
Curd, buttermilk	Brine mango
Jackfruit	Dried Zingiber officinale
Sesame oil	Salt water

5.2. Knowledge gaps and future scope

There are hindrances to the utilization of the principles and practices of this work. Prognostication using Jyotsnikā’s methods is often cumbersome and prone to miscalculations. This led to many toxicologists minimizing their prognostic criteria to omens [18].

The global [19] and national [20] guidelines contraindicate traditional interventions in snakebite due to lack of evidence and availability of proven treatment options like antivenom.

The text mentions other envenomation by other animals very briefly and drops out dūṣīviṣa and gara viṣa, which are potential Ayurvedic strongholds in today's sociolegal scenario.

The evidence support of formulations in Jyotsnikā is modest. There is only one clinical trial (in wasp sting) [21] and one case study (in viperine poisoning) [22] containing Śigrupunarnavādi lepa though several single drugs and their phytochemicals have been studied in vitro for antitoxic and antivenin activity.

Management of snakebite with antivenom has risks of complications like generalized hypersensitivity, serum sickness, and renal failure [23]. In settings with limited resources, herbal practices continue to be the mainstream intervention due to poor access to antivenom [24]. Several herbs in the Indian subcontinent and outside have been studied for their antitoxic, antihemorrhagic, anti-myotoxic, enzyme inhibiting, antivenin properties [25]. Ophiorrhiza mungos (a drug frequently used in Jyotsnikā) contained snake venom neutralizing compounds and reversed the hemorrhagic effects of Russel's viper venom (induced in chick embryos) when administered in high quantities [26]. The ethnopharmacological practices of snakebite envenomation management have also been documented [27]. Hence, there is room for exploring herbal candidates for snakebite management. The scope of herbal medicine shall be in synergistic [28] or standalone [29] antitoxic activity, arresting of tissue damage [30], and prevention of antivenom complications. Evidence from both field and laboratory are to be collated for this purpose. Practices like herb blowing and collyrium may also complement these medicines as first aids and alternate drug delivery routes. Further studies on their mode of action are also warranted.

Viṣavaidya practices can also be repurposed to treat infectious and non-infectious diseases. Dengue has been treated using the viper poison management strategy as both are pitta-rakta predominant in manifestation. Cysteine-rich venom proteins have been identified to be common factors in their pathogeneses [31,32]. In the non-infectious category, viṣa treatment principles are already used to manage allergic and autoimmune disorders [1,2].

Jyotsnikā and its contemporaries are artefacts that remind of multiple traditional toxicology lineages. Documentation of their practices and generation of their evidence at all levels are indispensable for the revival of this system.

Source of funding

Nil.

Declaration of competing interest

Nil.