AH-Su-Chapter 30: Kshar-Agni Karma Vidhi क्षारग्निकर्म विधि / Alkali and Thermal Cautery

Kshara Sresthata – advantages of alkaline cautery:-

सर्वशस्त्रा अनुशस्त्राणां क्षारः श्रेष्ठो बहूनि यत्
छेद्यभेद्यादिकर्माणि कुरुते विषमेष्वपि
बुःखावचार्यशस्त्रेषु तेन सिद्धिमयात्सु च
अति कृच्छ्रेषु रोगेषु यच्च पाने अपि युज्यते

Of all the sharp instruments and accessory instruments, Kshara (caustic alkali) is the best.
It performs many functions such as incising, excising etc;
It can be used even in inaccessible places.
Success can be obtained by its use even in diseases which are very difficult to cure and also because it can be used even in the form of a drink. 1 – 2.

Paneeya Kshara indication – 

स पेयो अर्शोग्निसादाश्मगुल्मोदरगरादिषु

In a drinkable form it is used in
Arsha – haemorrhoids,
Agnisada – dyspepsia,
Ashma – renal calculus,
Gulma – Tumors of the abdomen
Udara – ascites, enlargement of the abdomen
Garavisha – chronic poisoning etc.

Pratisarana Kshara Yogya -

योज्यः साक्षान्मषश्वित्रबाहयार्शः कुष्ठसुप्तिषु
भगन्दरार्बुदग्रन्थिदुष्टनाडीव्रणादिषु

In the form direct application, Kshara can be used in
Mashaka – moles – warts,
Shvitra – leucoderma,
Bahya Arsha – external piles,
Kushta – skin diseases
Supti – anesthetic patches,
Bhagandara – rectal fistula,
Arbuda – cancerous growth,
Granthi – tumour, fibroid
Dushta Nadi vrana – foul and sinus ulcers etc.

Kshara Nisedha – contra indication:-

न तूभयो अपि योक्तव्यः पित्ते रक्ते चले अबले
ज्वरे अतिसारे हृन्मूर्धरोगे पाण्ड्वामये अरुचौ
तिमिरे कृतसंशुद्धौ श्वयथौ सर्वगात्रगे
भीरुगर्भिण्यतुमतीप्रोदवृत्तफलयोनिषु
अजीर्णेअन्ने शिशौ वृद्धे धमनीसन्धिमर्मसु
 तरुणास्थिसिरास्नायुसेवनीगलनाभिषु
देशे अल्पमांसे वृषणमेढ्रस्रोतोनखान्तरे
वर्त्मरोगादृते अक्ष्णोश्च शीतवर्षोष्णदुर्दिने

Neither externally, nor internally, Kshara should be used in
Aggravation of Pitta and Rakta
and diminished Vata;
Jvara – fever
Atisara – diarrhoea, dysentery
Hrut Murdha Roga – diseases of the heart and head,
Pandu – anemia
Aruchi – anorexia,
Timira – blindness;
Kruta samshuddha – in those who have been administered Panchakarma therapies (recently),
Sarvagatra shvayathu – who have swelling of the entire body,
Bheeru – who are fearful, coward,
the pregnant, the menstruating woman, woman who has difficult menstrual flow, or woman who has displacement of either vagina or uterus;
Ajirne Anne – when the food remains undigested,
for infants and old persons,
on places of the body such as the arteries, joints, vulnerable spots, cartilages, veins, tendons/nerves, sutures, throat, umbilicus and places which are poor of muscles, the testes, penis, orifices, passages, interior of the nails;
In diseases of the eyes except those of the eyelids; during cold, rainy and hot seasons and on days when the sun in not seen. 4 – 7.

Kshara Nirmana – preparation of caustic alkali:-

कालमुष्ककशम्याककदलीपारिभद्रकान्
अश्वकर्णमहावृक्षपलाशास्फोतवृक्षाकान्
इन्द्रवृक्षार्कपूतिकनक्तमालाश्वमारकान्
काकजङ्घाममपामार्गमग्निमन्थाग्नितिल्वकान्
सार्द्रान्समूलशाखादीन् खण्डशः परिकल्पितान्
कोशातकीश्चतस्रश्च शूकं नालं यवस्य च
निवाते निचयीकृत्य पृथक् तानि शिलातले
प्रक्षिप्य मुष्ककचये सुधाश्मानि च दीपयेत्
ततस्तिलानां कृतलैर्दग्ध्वाअग्नौ विगते पृथक्
कृत्वा सुधाश्मनां भस्म द्रोणं द्वितरभस्मनः
मुष्ककोत्तरमादाय प्रत्येकं जलमूत्रयोः
गालयेदर्धभारेण महता वाससा च तत्
यावत्पिच्छिलरक्ताच्छस्तीक्ष्णोजातस्तदा च तम्
गृहीत्वा क्षारनिष्यन्दं पचेल्लोह्यां विघट्टयन्
पच्यमाने ततस्तस्मिस्ताः सुधामस्यशर्कराः
शुक्तिः क्षीरपकं शङ्खनामीश्चायसभाजने
कृत्वा अग्निवर्णान्बहुशः क्षारोत्थेकुडवोन्मिते
निर्वाप्य पिष्ट्वा तेनैव प्रतीवापं विनिक्षिपेत्
शलक्ष्णं शक्रुद्दक्षशिखिगृध्रकङ्ककपोतजम्
चतुष्पात्पक्षिपित्तालमनोहवालवणानि च
परितः सुतरां चातो दार्व्या तमवघट्टयेत्
सबाष्पैश्च यदोत्तिष्ठेद्बुद्बुदैर्लेहवद्धनः
अवतार्य तदा शीतो यवराशावयोमये
स्थाप्यो अयं मध्यमः क्षारो                         

Moist roots, branches and other parts of trees such as Kalamushkaka, Shamyaka, Kadali (Banana), Paribhadraka, Ashvakarna, Mahavriksha, Palasha, Asphota, Vrikshaka, Indravriksha, Arka, Putika, Naktamala, Ashvamaraka, Kakajangha, Apamarga, Agnimantha, Agni or Tilvaka – are cut into small pieces and placed on clean stone slabs, separately, in heaps;
Pieces of the four kinds of Koshataki plants, the spikes and reeds of Yava (barley) plants are also similarly heaped.
Into the heap of Kalamushkaka, pieces of lime stone are put in.
All the heaps are set on fire by making use of dried chaff of Tila plant (Sesame plant).
After the heaps have been well burnt and fire has disappeared, one Drona (12,288 g) of ash of lime stone together with ash of Kalamushkaka and one and a quarter Drona (3072 g) of ash of others are taken, mixed together, dissolved well in half Bhara (48000 g) of water and cows urine separately, and filtered through a thick cloth till a slimy, reddish, clear and penetrating alkaline material is obtained.
It is then transferred into an iron cauldron and cooked, stirring it constantly with a ladle;
To this is added one Kudava (192 g) of ash of limestone, shells of mother of pearls, Kshirapaka (Khatika or clay), spiral of conch shell – each made red hot over a pan, fine powder of excreta of cock, peacock, falcon, heron and pigeon, bile of quadrupeds and birds, Ala ( haritala-Orpiment), Manohva (Realgar) and salts, all these are ground into a paste and mixed with the boiling solution, stirring it all the while from all sides.
When it begins to emit fumes, bubbles come up and attains a solid consistence like a confection (Avaleha), the cauldron should be taken out of fire.
When it gets cool, it is transferred into an iron vessel which is kept concealed inside a heap of Yava (barley) for some days.

This is the mode of preparing Madhyama Kshara – alkali of medium potency. 8 – 19½.

For preparing Mrudu Kshara (Kshar of Mild Potency) –

न तु पिष्ट्वा क्षिपेन्मृदौ
निर्वाप्यापनयेत्तीक्ष्णे पूर्ववत् प्रतिवापनम्
तथा लाङ्गलिकादन्तिचित्रकातिविषावचाः
स्वर्जिकाकनकक्षीरिहिङ्गुपूतीकपल्लवाः
तालपत्री विडम् चेति, सप्तरात्रात्परं तु सः
योज्यः

alkali of mild potency, the admixture – ash of shells, powder of excreta, biles etc. should not be made into a paste and added but put in powder form and taken out – filtered and thrown away.

For preparing Teekshna Kshara – alkali of strong potency the admixture should be similar to that of previous – alkali of medium potency and also the paste of Langalika, Danti, Chitraka, Ativisha, Vacha, Svarjika, Kanakaksiri, Hingu, sprouts of Putika, Talapatri and Bida salt and alkali prepared as usual and used after a lapse of seven days. 20 – 21½.

Trividha Kshara Yojana – indications of three kinds of alkali:-

तीक्ष्णो अनिलश्लेष्ममेदोजेष्वर्बुदादिषु
मध्येष्वेष्वेव मध्योअन्यः पित्तास्रगुदजन्मसु
बलार्थं क्षीनपानीये क्षाराम्बु पुनरावपेत्

Teekshna Kshara – Alkali of strong potency should be used in diseases arising from Vata, Kapha, Medas – fat,
Arbuda – cancerous growth and such others which are very difficult to cure,
Madhyama Kshara – alkali of medium potency is useful in those diseases when they are of moderate strength, not very difficult to cure. Mrudu Kshara – Mild alkali is used In diseases arising from Pitta and Asra – Rakta and heamorrhoids,
When the alkali loses its water content some quantity of alkali solution should be added to strengthen it. 22 – 23.

Ksharaguna – properties and actions of alkali:-

नातितीक्ष्ण मृदुः श्लक्षणः पिच्छिलः शीघ्रगः सितः
शिखरी सुखनिर्वाप्यो न विष्यन्दी न च अतिरुक् २४
क्षारो दशगुणः शस्त्रतेजसोरापि कर्मकृत् आचूषन्निव संरम्भोद्गात्रमापीडयन्निव २५
सर्वतो अनुसरन् दोषानुन्मूलयति मूलतः
कर्म कृत्वा गतरुजः स्वयमेवोपशाम्यति २६

Na ati teekshna – Neither too strong
na ati mrudu – nor too mild,
Shlakshna – smooth,
Picchila – slimy,
Sheeghraga – quick in spreading
Sita – white in colour,
Shikhari – remaining like a mountain peak at the site of application, Sukha nirvapya – easily removable,
Na vishyandi – producing neither too much of exudation / moistness
Na ati ruk –does not cause much pain
These are the ten ideal qualities of the caustic alkali.
It does all the functions of the sharp surgical instrument and also the fire.
By actions such as sucking quickly, healing effect over the body, spreading everywhere, it pulls out all the Doshas (vitiating materials) by their root;
After such actions when the diseases disappears, Kshara also subsides on its own accord. 24 – 26.

Kshara Prayoga – procedure of Alkaline cauterization :-

क्षारसाध्ये गदे छिन्ने लिखिते स्राविते अथवा
क्षारं शलाकया दत्त्वा प्लोतप्रावृतदेहयो
मात्राशतमुपेक्षेत

The disease treatable by alkali should either be cut, scraped / made to exude fluid first.
Then the alkali taken in an iron rod, is placed on the spot, the other parts surrounding of the body kept covered and protected by cotton swabs and a time period of one hundred Matra awaited. 27.

तत्रार्शः स्वावृताननम्
हस्तेन यत्नं कुर्वीत वर्त्मरोगेषु वर्त्मनी
निर्भुज्य पिचुना आच्छाद्य कृष्णभागं विनिक्षिपेत्
पद्मपत्रतनुः क्षारलेपो, घ्राणार्बुदेषु च
प्रत्यादित्यं निषख्णस्य समुन्नम्याग्रनासिकाम्
मात्रा विधार्यः पञ्चाशत् तद्वद्र्शसि कर्णजे

In haemorrhoids, if the tip of the pile mass is found concealed, it should be manipulated by the hand in such way as to place the alkali on them, inside the anal canal.
In diseases of the eyelids, the lids are to be everted, the black area – cornea kept covered with cotton swab as protection and then alkali applied as thin as of a lotus petal to the interior of the lids.

In cancer of the nose, the patient is made to sit facing the sun, the tip of the nose is raised up and alkali applied into the nostril and a time of fifty Matra Kala awaited;
In case of piles, polyp of the ears also it shall be similar. 28 – 30.

क्षारं प्रमार्जनेनानु परिमृज्यावगम्य च
सुदग्धं घृतमध्वक्तं तत्पयोमस्तुकाञ्जिकैः
निर्वापयेत्ततः साज्यैः स्वादुशीतैः प्रदेद्दयेत्
अभिष्यन्दीनि भोज्यानि भोज्यानि क्लेदनाय च
यदि च स्थिरमूलत्वात्क्षार दग्धं न शीर्यते
धान्याम्लबीजयष्ट्याःवतिलैरालेपयेत्ततः
तिलकल्कः समधुको घृताक्तो व्रणरोपणः

Afterwards the prescribed time the alkali is wiped off with a cotton swab etc. and perceiving that the site has been properly burnt by the alkali, a mixture of ghee and honey should be applied, made cool by pouring milk, whey or sour gruel, and then applying a paste of drugs of sweet taste and cold potency.

The patient should consume foods which produce more secretions in the tissue cells in order to moisten the site of burn. If the site of the burn does not get torn from an ulcer because of being deep rooted, then a paste of seed of Dhanyamala-(sour gruel), Yashti (licorice) and tila (sesame) should be applied;

तिलकल्क: समधुको घृताक्ता व्रणरोपण: ।

Paste of tila (sesame), and Madhuka mixed with ghee heals the ulcer. 31-33 ½

पक्वजम्ब्वसितं सन्नं सम्यग्दग्धम् विपर्यये ३४
ताम्रतातोदकण्ड्वाद्यैर्दुर्दग्धम् तं पुनर्दहेत्

Symptoms of good burning due to Kshara – Attaining black color, similar to the ripe fruit of Jambu (Jamun fruit),
depression of the site- are the feature of a samyag dagdha.
The opposite of it, that is appearance of
Tamravarna – coppery red color,
pricking pain, itching etc. are the features of Durdagdha improper- inadequate burning, such an area should be burnt again. 34

Atidagdha- over-burning

अतिदग्धे स्रवेद्रक्तं मूर्च्छादाहज्वरादयः
गुदे विषेशाद्विण्मूत्रसंरोधो अतिप्रवर्तनम्
पुंस्तोपघातो मृत्युर्वा गुदस्य शातनाद्ध्रुवम्
नासायां नासिकावंशधरणाकुञ्चनोद्भवः
भवेच्च विषयाज्ञानम् तद्वच्च श्रोत्रादिकेषु अपि

Atidagdha- over-burning produces bleeding, fainting, burning sensation, fever etc.
Over-burning of the Anus- rectum produces obstruction for passing of feces and urine or their excess elimination, loss of muscular and sexual power (impotency) and death.
In case of the nose, there will be severe burning sensation, contraction of the nasal bridge and loss of sense of smell; similarly so in case of ears etc other sense organs.  35-37

विशेषादत्र सेको अम्लैर्लेपो मधु घृत तिलाः
वातपित्तहरा चेष्टा सर्वैव शिशिरा क्रिया
अम्लो हि शीतः स्पर्शेन क्षारस्तेनोपसंहितः
यात्याशु स्वादुतां तस्मादम्लैर्निर्वाप्येत्तराम्

In such conditions, burning the part with sour fluids, applications of paste of honey, ghee and Tila (sesame),
activities- foods other comforts which mitigate Vata and Pitta and all others which produce cold, should be adopted.
As sour is cold to touch, combining with the Alkali it quickly attains the properties of sweet taste, hence the burn caused by Alkali should be washed with sour substances quickly. 38-39.

विषाग्निशस्त्राशनिमृत्त्युतुल्यः क्षारो भवेदल्पमतिप्रयुक्तः
स धीमता सम्यगनुप्रयुक्तो रोगान्निहन्यादचिरेण घोरान्

Kshara administered by the physician of poor intellect is like death caused by poison, fire, sharp weapon, or thunderbolt;
Whereas done properly by an intelligent physician it cures even dreaded diseases quickly.

Agni karma- thermal cautery- branding:-

अग्निः क्षारदपि श्रेष्ठस्तद्दग्धानामसम्भवात्
भेषजक्षारशस्त्रैश्च न सिद्धानां प्रसाधनात् ४०

Fire- thermal cautery is better than even the Kshara, for the diseases that are treated by Agnikarma do not recur and it can be used even in diseases which have not been successful treated by Drugs, Kshara or Shastrakarma (surgery). 40

Agnikarma Yojana- indications and contraindications for thermal cautery :-

त्वचि मांसे सिरास्नायुसन्ध्यस्थिषु स युज्यते
मषाङ्गग्लानिमूर्धार्तिमन्थकीलतिलादिषु
त्वग्दाहो वर्तिगोदन्तसूर्यकान्तशरादिभिः

It is used on the skin, muscle, vein, tendon, joints and bones.
In diseases like black moles, weakness of body parts, headache, Adhimantha- a disease of the eye, warts, cysts etc. burning of the skin should be done either with a lighted wick, tooth of a cow, rock crystal, arrow head or others – such as Pippali, excreta of goat, iron- rod, piece  of bangles. 41

अर्शोभगन्दरग्रन्थिनाडीदुष्टव्रणादिषु
मांसदाहो मधुस्नेहजाम्बवौष्ठगुडादिभिः

Haemorrhoids, rectal fistula, tumors, sinus ulcers and bad- septic, longstanding, foul ulcers etc. should be treated by burning of the muscles with- hot honey, fats, Jambavostha- an iron instrument with a spoon shaped tip, jaggery- treacle etc. 42

श्लिष्टवर्त्मान्यसृक्स्रावनील्यसम्यग्व्याधिषु
सिरादिदाहस्तैरेव

Slishtavartma-exudative disease of the eyelids, bleeding, blue mole, improper cutting- surgical wound etc. burning of the veins should be done by – using the same materials enumerated in the previous verse. 43

Contra indication for Agni karma – 

न दहेत्क्षारवारितान्
अन्तःशल्यासृजो भिन्नकोष्ठान् भूरिव्रणातुरान्

Burning should not be done for those who are not suitable for Kshara karma,
wounds which have foreign body or accumulation of blood inside,
persons who have perforation of abdominal viscera and
those who are suffering from severe wounds. 44

सुदग्धं घृतमध्वक्तं स्निग्धशीतैः प्रदेहयेत्

The site which has been burnt properly – by fire should be given a coating of ghee and honey and an application of paste of drugs which are unctuous and cold in potency. (snigdha, sheeta)

Daha laksana- features of proper and improper burning:-

तस्य लिङ्गं स्थिते रक्ते शब्दवल्लसिकान्वितम् ॥४५॥

पकतालकपोताभं सुरोहं नातिवेदनम् ।

The signs of samyak dagdha- proper burning are stoppage of bleeding, emergence of crackling sound accompanied with lymph, the area having color resembling a ripe Tala fruit or pigeon dark grey. The wound healing easily and not much of pain .45

The signs of inadequate burning and excess burning 

प्रसाददग्धवत्सर्वं दुर्दग्धात्यर्थदग्धयोः
चतुर्धा तत्तु तुच्छेन

The signs of inadequate burning and excess burning are similar to those of improper burning.
Burning is of four kinds, together with

Tuccha Dagdha- bad/ mean/ undesirable/ inadequate burning.

तुच्छ दग्ध लक्षण – The signs of tuccha dagdha 

सह तुच्छस्य लक्षणं । त्वक् विवर्ण उष्यते अत्यर्थं न च स्फोटसमुद्भव: ॥४७॥
सस्फोटदाहतीव्रोषं दुर्दग्धं अतिदाहतः
मांसलंबनसङ्कोचदाहधूपनवेदनाः
सिरादिनाशस्तृण्मूर्च्छाव्रणगाम्भीर्यमृत्यवः

The signs of tuccha dagdha are discoloration of the skin, severe burning sensation,

Signs of atidagdha- over burning are
Mamsalambana – dropping down of the muscles,
sankocha – constriction,
Daha – burning sensation
Dhupana – feeling  of hot fumes coming out,
vedana –  pain
Siradi nasha – destruction of veins etc,
Trut – excessive thirst
Murcha – fainting, loss of consciousness
Gambhira Vrana –worsening of the wound and
Mrutyu – death. 46-48 ½

तुच्छस्याग्निप्रपतनं कार्यमुष्णं च भेषजम्
स्त्याने अस्रे वेदना अत्यर्थं विलीने मन्दता रुजः

A Tuccha Dagdha- bad/ inadequate burning- should be burnt once again and paste of drugs which are hot in potency, should be used; when the blood is coagulated there is severe pain and when it is dissolved pain is mild. 49

दुर्दग्धे शीतमुष्णं च युञ्ज्यादादौ ततो हिमम्

In case of Durdagdha- improper burning clod and hot treatment should be used, the hot one first and the cold one next. 50

सम्यग्दग्धे त्वक्षीरिप्लक्षचन्दनगैरिकैः
लिम्पेत्साज्यामृतैरूर्ध्वं पित्तविद्रधिवत्क्रिया

In case of Samyagdadha- proper burning, a paste of Tavaksiri, Plaksha, Chandana (Sandalwood), Gairika (Red ochre) and Amrita (Tinospora) mixed with ghee should be applied on the area of burn and then therapies indicated for an abscess of Pitta origin should be adopted. 51

अतिदग्घे द्रुतं कुर्यात्सर्वं पित्तविसर्पवत् ।
स्नेहदग्घे भृशतरं रुक्षं तत्र तु योजयेत् ॥५२॥

In case of Atidagdha- over burning all the therapeutic measures prescribed for Visarpa of Pitta origin should be done quickly.

In case of burning by fats- hot oil, ghee etc, measures which are very dry- cause severe dryness should be adopted. 52

शस्त्रक्षाराग्नेयो यस्मान्मृत्योः परममायुधम्
अप्रमत्तो भिषक् तस्मात्तान् सम्यगवचारयेत्

The knife, Alkali and fire are chief weapons of the lord of death; hence the physician should administer them with great care.

Thus will be concluded, this section of Astanga Hrudaya which  is full of secrets, for in it are codified all the  chief doctrines which  are described in detail everywhere – in the entire treatment. 53

Thus ends the thirty chapter called KsharAgni Karma Vidhi in sutrasthana of Astanga hrudaya composed by Vaghata.