Kshara

Kshara is a kind of medication described in Ayurveda Texts for the management of various disorders . The word Kshara(क्षार) is derived from the root Kshar(क्षर्), means to melt away or to perish (क्षर् स्यन्दने). Acharya Sushruta defines as the material which destroys or cleans the excessive/the morbid doshas (Kshyaranat Kshyananat va Kshara). According to the preparation we can consider it to be caustic materials, obtained from the ashes after distillation and are mostly alkaline in nature.^[1][2]

Types of Kshara

According to the administration it is of two type 1. Paniya Kshara(for internal Medication) and 2. Pratisaraniya Kshara'(external application). The Paniya Kshara is mostly used for the treatment of diseases like artificial poison, abdominal lump, indigestion, calculus etc. The Pratisaraniya Ksara is used to apply on tumors, piles, fistula in ano, skin diseases etc.^[3]

Drugs Used

Many drugs have been advised by Sushruta and other Ayurvedic texts for the preparation of Kshara. The important among them are - Palasa- Butea monosperma, Erythrina indica, Terminalia belerica, Cassia fistula, Plumbago zeylanica, Holarrhena antidysenterica etc.

Method of Preparation

According to the three types of Ksharas are prepared on the basis of their strength. 1. Mild - Mridu, 2. Moderate - Madhyama and 3. Strong - Tikshna .The general procedure can be narrated as - 'Mridu' Bhașmīkaraņa (conversion to ash) Adding to water(1:6 ratio) Filtration(21 times) Distillation(boiling the ksarajala still all water evaporates) collection (process called lixiviation) 'Madhyama' Here the procedure is same some extra powders of Katasarkara Bhasma sarkara Ksheerapaka, Samkhanabhi( gravels of lime and ash,oyester-shell & core of conch-shell) are added to the boiling ksharajala before distilling it. 'Tikshna' Similar to madhyama kshara here added is the powders of drugs like Chitraka, danti, vacha etc. inplace of the lime stones.

Kshara Sutra

"Kshar Sutra" (क्षारसूत्र) is a sanskrit phrase in which Kshar (क्षार) refers to anything that is corrosive or caustic; while Sutra(सूत्र) means a thread.It is described by many Ayurvedic texts which originated and flourished in India. It is one among popular Ayurvedic treatment modality in the branch of Salyatantra followed by Susruta.

The Ksharsutra was first mentioned by the "Father of Surgery" Sushruta in his text named SUSHRUT - SAMHITA for the treatment of Nadi Vrana(sinus), Bhagandara (fistula- in - ano), arbuda(excision of small benign tumour) etc..Although Brihattrayi- the chief three texts of Ayurveda mention the use of kshara sutra,there is no description of their preparation properly. It was Chakrapani Dutta in late eleventh century in his book Chakradatta, first mentioned the method of preparation with a clear-cut indication of its use in bhagandara and arsha(haemorrhoid). In his book Chakradutta explains the method that by smearing a sutra (thread) repeatedly in the latex of snuhi() and haridra(turmeric) powder makes the kshara sutra. Later authors like Bhavamishra, Bhaisajyaratnavali etc. also mention the same method. But because of brevity of preparation and inadequate explanation of procedure of application, it lost its popularity among Ayurvedic surgeons. Later in Rasatarangini a better preparation procedure was introduced still the credit of making it practically in use goes to Prof. P.J.Deshpande, his research officer Dr. S.R. Gupta and his coworkers. They rediscovered and standardized the ksharasutra in the present era . The Dept. of Shalya- Shalakya, Faculty of Ayurveda, IMS, BHU should be credited for the abundant use and popularization of this technique.^[4]

Method of preparation

The standard kshar sutra is prepared by repeated coatings of snuhi ksheera (latex of Euphorbia Nerrifolia), apamarg kshara (ash of Achyranthus aspera) and haridra powder over a surgical linen thread no. 20. This thread is spread throughout lengthwise in hangers. Each thread on the hanger is then smeared with snuhi latex with the help of gauze piece soaked in the latex. This wet hanger is transferred in kshara sutra cabinet. The same process is repeated next day. Eleven such coatings with snuhi ksheera alone should be accomplished. The twelfth coating is done by first smearing the thread with ksheera and in wet condition thread is passed through the apamarg kshar. It is again transfer into the cabinet for drying. This process is repeated till seven coatings of snuhi ksheer and apamarg kshara are achieved. The final three coatings are completed with snuhi ksheera and fine powder of turmeric in the same fashion. Thus twenty-one coatings over the thread are completed.,^[5][6]

Ksharsutra preparation details

Mode of Action

Kshar Sutra is now a popular treatment modality in India for the management of fistula in ano, piles, fissure tag, pilo-nodal sinus. Many Clinical trials have done all over in different institutes to evaluate the action. In countries like Sri Lanka and Japan also many clinical trial has already done and established it. Precisely the action of Kshara sutra is thought to be due to its healing and cleansing effect according to Ayurveda. It can be suggested that due to the anti microbial action, and as a Seton it allows the proper drainage of pus from the fistula, that leads to a proper healing. On the other hand, the cutting effect of thread incises the skin gradually without a surgical incision. Many studies confirms that it is more effective in the way of reducing hospital stay and less infection than the conventional seton therapy.Researches suggests that it is having the action of Excision, Scrapping, Draining, Penetrating, Debridement, Sclerosing and Healing. It is Bactericidal and Bacteriostatic.,^[7] paniya kshara act through changing internal environment of body (prakit vighata concept of ayurveda).

Types of Kshar Sutra

In the textual reference of Chakradatta and Rasatarangini we get only indication of the thread made up of Snuhi, apamarga and Turmeric. Susruta describes about many kind of Kshars like Karaveera, Palasa, Kadali etc. in Susruta Samhita. So many studies have already carried out with variations in the Kshara and the latex. The most remarkable are Guggulu Ksharasutra, Udumbara KS, Gomutra KS, Papaya KS, KS with Ficus carica latex etc.^[8][9]

Kshara Sutra treatment centres in India

1. Department of Shalya, Institute of Medical Sciences, BHU, Varanasi

2. Department of Shalya, Gujarat Ayurved University, Jamnagar, Gujarat

3. National Institute of Ayurveda, JAIPUR

4. Department of salya tantra ,Sri Venkateswara ayurvedic college and Hospitals, Tirupathi.

5. Deepak Ayurvedic Centre, Delhi

6. All India Institute of Ayurveda, Sarita Vihar, New Delhi

7. Brahm Health Care, Ghaziabad

8. Government Ayurveda College, Lucknow

9. J. B. Roy State Ayurvedic Medical College & Hospital, Kolkata

10. All India Institute of Medical Sciences, New Delhi

11. All India Institute of Medical Sciences, Patna

12. Sri Kala Byraveshwara Swamy Ayurvedic Medical College Hospital & Reaserch Center, Bangalore

12. Shreyas Ano-rectal hospital & research center

13. Ayurvedic And Unani Tibbia College, Karol Bagh, New Delhi

14. Dr. Shubham Puri, Nirog Chikitsa Kendra,TV Tower Road, Near Durga Temple, Raigarh, Chhattisgarh, 496001

15. Dr. M. M. Salimath, Department Of Shalyatantra, Sri Jagadaguru Gavisiddheswar Ayurved Medical College & Hospital, Gavimath Campus, Koppal, Karnataka, 583231

References

1. Sabda Kalpadrima
2. Susruta Samhita 3/11
3. Susruta Samhita 11
4. A hand book of Anorectal Disorders and their Ayurvedic Management, Dept. of Salyatantra , GAC, Tripunithura, Kerala
5. A Handbook of Anorectal Disorders and their Ayurvedic Management, Dept. of Salyatantra, GAC, Tripunithura, Kerala
6. Anal Fistula and KST, Pathak S.N., Chawkhamba Krishnadash Academy, Varanasi
7. Shukla, N.K. Narang, R. Nair, N.G.K., Radhakrishna, S., Satyavati, G.V.: Multicentric randomized controlled clinical studies of Kshara-sootra in management of fistula-in-ano. Indi J. Med. Res. (B), 177-185, 1994
8. Thakur abhiram at al , Kshara sutra therapy a new dimension, souvenir-Anusastra 2008, Dept. of Salyatantra, GAC, Tripunitura, Kerala
9. Ghanekar BG , Susruta Samhita, Sutra sthana 11, ML Publication, New Delhi,1998