Sushruta Samhita Sutrasthana Chapter 11: Ksharapaka Adhyaya (Preparation of Caustic Alkali)

The 11th chapter of Sutrasthana of Sushruta Samhita is named as Prabhashaniya Adhyaya. This chapter deals with the information on facilitating the study.

अथातःक्षारपाकविधिमध्यायं व्याख्यास्यामः॥१॥
यथोवाचभगवान्धन्वन्तरिः॥२॥
We will now expand the chapter,by name ksharapakavidhi- preparation of caustic alkali;as revealed by the venerable Dhanvantari.

Kshara Mahatva: Importance of Alkali

शस्त्रानुशस्त्रेभ्यःक्ष्गरःप्रधानतमः,छेद्यभेद्यलेख्यकरणात्रिदोषघ्नत्वाद्विशेषक्रियावचारणाञ्च॥३॥
Among the sastra (sharp instruments) and anusastra (accessory instruments) – kshara (caustic alkali) is the most important one because –

• it serves the functions like chedana – excision (removing), bhedana – cutting (dividing) and lekhana – scraping,
• it is prepared by many herbs,
• it mitigates all the three doshas and
• it is suitable for being used in many special procedures
• Nirukti: Definition

तत्रक्ष

णात्क्षणनाद्वाक्षारः॥४॥

It is called kshara, since it destroys – ksharana (the vitiated tissues and makes them fall off) or since it torments – kshanana (the tissues).

Ksharaguna: Properties of Alkali

नानौषधिसमवायात्रिदोषघ्नः,शुक्लत्वात्सौम्यः,तस्यसौम्यस्यापिसतोदहनपचनदारणादिशक्तिरविरुद्धा,अग्रेयोषधिगुणभूयिष्ठत्वात्कटकउष्णस्तीक्ष्णःपाचनोविलयनःशोधनोरोपणःशोषणःस्तम्भनोलेखनःकृम्यामकफकुष्ठविषमेदसामुपहन्तापुंस्त्वस्यचातिसेवितः ॥५॥

The kshara is prepared by the combination of many herbs / drugs. Therefore, it mitigates tridoshas. (Alkali is prepared using many herbs which are useful in destroying the morbid tridoshas. Hence, they are useful in combating aggravation of all three doshas).
Since kshara is white in color, it is cool in nature. In spite of being cool it would preserve its actions including burning, ripening, and bursting.
kshara is prepared using drugs / herbs which are predominant in Agneya guna (having fiery nature). Therefore, it is pungent in taste and hot in potency. Due to the same qualities, it is deep penetrating.
Due to these qualities Kshara also does –

• Pacana – causes ripening of swelling around wounds – vrana sotha etc.,
• Vilayana – liquefaction of gulma – tumors etc.
• Shodhana – purification / cleansing of contaminated wounds and ulcers,
• Ropana – healing (of clean wounds – shuddha vrana),
• Shoshana – absorption (of fluids – dampness or excessive moistness of wounds / ulcers),
• Stambhana – withholding things (stops bleeding – checks excessive bleeding), and
• Lekhana – scarification (of hard and elevated tissues including muscles)
  Other benefits –
• Krimi upahanti – It destroys worms (bacteria, virus etc),
• Amam upahanti – destroyed undigested materials,
• Kapham upahanti – destroys morbid kapha
• Kushtam upahanti – destroys / cures skin diseases / leprosy
• Visham upahanti – destroys the poisons and effects of poisons
• Medam upahanti – destroys excessive accumulation of fats / obesity
  If alkali is taken in excess, it destroys masculinity (sexual powers in male).
  

Kshara Vidha: Kinds of alkali

स द्विविधः- प्रतिसारणीयः,पानीयश्च॥६॥
There are two kinds of kshara i.e.

1. Pratisaraniya kshara – meant for external application and
2. Paniya kshara – meant for internal administration i.e. to be drunk (internal potion)

Pratisaraniya Kshara

तत्रप्रतिसारणीयःकुष्ठकिटिभदद्रुमण्डलकिलासभगन्दरार्बुदार्शोदुष्टव्रणनाडीचमंकीलतिलकालकन्यच्छव्यङ्गमशकबाद्यविद्रधिकृमिविषादिषूपदिश्यते;सप्तसुचमुखरोगेषूपजिह्वधिजिह्वोपकुशदन्तवैदर्भेषुतिसृषुचरोहिणीषुएतेष्वेवानुशस्त्रप्रणिधानमुक्तम्॥७॥
Pratisaraniya kshara i.e. application of caustic alkali externally is indicated in the below mentioned conditions –

• Kustha – leprosy
• Kitibha, Dadrumandala – minor skin diseases
• Kilasa – leucoderma
• Bhagandara – fistula-in-ano
• Arbuda – malignant tumors
• Arsha – piles / hemorrhoids
• Dusta vrana – vitiated (septic) ulcers
• Nadi – sinus ulcers
• Carmakila – skin warts
• Tilakalaka – pinheads
• Nyaccha – pigmented patches on the body and face
• Vyanga – pigmented patches on the face
• Masaka – moles on the skin
• Bahya Vidradhi – external abscess
• Krmi – worms (bacteria etc)
• Visa – diseases produced by poisons / poisoning
• Seven diseases of the mouth including – Upajihva, Adhijihva, Upakusa, Dantavaidarbha and three kinds of Rohini / Kantarohini (Vataja Rohini, Pittaja Rohini and Kaphaja Rohini)
• Etesu anusastra pranidanam uktam – in all those diseases wherein use of accessory instruments has been indicated
  

Paniya Kshara

पानीयस्तु गरगुल्मोदराग्रिसङ्गाजीर्णारोचकानाहशर्कराश्मर्याभ्यन्तरविद्रधिकृमिविषार्शःसूपयुज्यते॥८॥
Paniya kshara i.e. drinking of the solution of alkalies is indicated in the below mentioned conditions –

• Gara visa – artificial poisons
• Gulma – abdominal tumors
• Udara – enlargement of abdomen
• Agnisanga – diminished digestive power (irregularities or impairment of digestive capacity and disorders resulting from the same)
• Ajirna – indigestion
• Arocaka – loss of taste / anorexia
• Anaha – flatulence / distension of abdomen
• Sarkara – urinary gravel
• Asmari – urinary calculi
• Abhyantara vidradhi – internal abscess
• Krmi – worms
• Visa – poisons
• Arsha – hemorrhoids

Contraindications for administration of Paniya kshara

अहितस्तुरक्तपित्तज्वरितवित्तप्रकृतिबालवृद्धदुर्बलभ्रममदमूर्च्छातिमिरपरीतेभ्योऽन्येभ्यश्र्चैवंविधेभ्यः॥९॥
Paniya kshara is contraindicated in the below mentioned conditions and people (since it is harmful in these conditions) –

• Raktapitta – bleeding disorders
• Jwarita – fevers
• Pitta prakrti – those belonging to pitta constitution / body type
• Balaka – children
• Vrddha – old aged people
• Durbala – debilitated persons
• Bhrama – giddiness / those suffering from dizziness
• Mada – intoxication
• Murcha – fainting
• Timira – blindness
• and similar ailments

Method of preparation of Paniya kshara

तंचेतरक्षारवह्दग्ध्वापरिरस्त्रावयेत्;तस्यविस्तरोऽन्यत्र॥१०॥

Paniya Kshara – To prepare this alkali, the drugs used for preparation of alkali should be burnt / incinerated. Later a solution of these burnt drugs is prepared. Its method of preparation is the same as that of other ksharas, the details of which will be described elsewhere.

Ksharanirmana: preparation of Alkali

अथेतरस्त्रिविधोमृदुर्मध्यस्तीक्षणश्च।टंचिकीर्षुःशरदिगिरिसानुजंशुचिरुपोष्यप्रशेस्तेऽहनिप्रशस्तदेशजातमनुपहतंमध्यमवयसंमहान्तमसितमुष्ककमधिवास्यापरेद्युः पाटयित्वाखण्डशः प्रकल्प्यावपाटच्निवातेदेशेनिचितिंकृत्वासुधाशर्कराश्चप्रक्षिप्यतिलनालैरादीपयेत्।
अथोपशान्तेऽग्रौतद्भस्म पृथग्गृह्णीयाद्भस्मशर्कराश्च।
अथानेनैवविधानेनकुटजपलाशाश्वकर्णपारिभद्रकविभीतकारग्वधतिल्वकार्कस्नुह्यापामार्गपाटलानक्तमालवृषकदलीचित्रकपूतीकेन्द्रवृक्षास्फोताश्वमारकमप्तच्छदाग्रिमन्थगुञ्जाश्चतस्त्रश्चकोशातकीः समूलफलपत्रशाखादहेत्।ततःक्षारद्रोणमुदकद्रौणैःषड्भिरालोड्चमूत्रैर्वायथोक्तैरेकविंशतिकृत्वःपरिस्त्राव्य,महतिकटाहेशनैर्दर्व्याऽवघट्टयन्विपचेत्।सयदाभवत्यच्छोरक्तस्तीक्ष्णःपिच्छिलश्चतमादायमहतिवस्त्रेपरिस्त्राव्येतरंविभज्यपुनरग्रावधिश्रयेत्।ततएवक्षारोदकात् कुडवमध्यर्धंवाऽपनयेत्।ततःकटशर्कराभस्मशर्कराक्षीरपाकशङ्खनाभीरग्रिवर्णाःकृत्वाऽऽयसेपात्रे
तस्मिन्नेवक्षारोदके निषिच्यपिष्टवा तेनैवद्विद्रोणेऽष्टपलसंमितंशङ्खनाभ्यादीनांप्रमाणं प्रतिवाप्य,सततमप्रमत्तश्चैनमवघट्टयन् विपचेत।सयथानातिसान्द्रो नातिद्रवश्चभवतितथाप्रयतेत।अथैनमागतपाकमवतार्यानुगुप्तमायसेकुम्भेसंवृतमुखेनिदध्यादेषमध्यमः॥११॥
The other kshara i.e. Pratisaraniya kshara – meant for external application is of three kinds viz –

• Mrdu – alkali having mild power
• Madhyama – alkali having medium strength
• Tiksna – alkali which is powerful / of immense strength

The person (physician) who desires to prepare kshara should follow the below mentioned procedures –
He should choose an auspicious day during Sharad Rtu – autumn season. He should cleanse himself and observe fasting. Later he should reach the peaks (slopes) of the mountain on the chosen day. He shall search for a Kala Muskaka tree grown in the auspicious regions of these peaks. This tree should be of middle age (enriched with taste and potency) and big in size. The power (effect) of its potency should not have been destroyed by the effect of cold, rains, fire, poisons and insects (worms etc). On the first day the physician should offer worship and oblations to the tree (enchant hymns in favor of the tree and induce power in the same). On the second day (next day) the tree should be de-rooted. Its stem and branches should be cut into small pieces with the help of an axe and stored in the form of a heap in a place devoid of breeze. On this heap one should add some quantity of small pieces of sudha sarkara i.e. lime stones (some limestones shall be placed beneath the heap and some in the between). This heap should be put on fire (burnt) with the help of dried reeds of Tila (sesame) plant. Ashes of the tree shall be collected in a separate vessel and that of the limestone in a separate one, after the fire gets extinguished all by itself.
In the same manner, the below mentioned plants / trees along with their roots, stem, branches, leaves and fruits shall be burnt and their as collected –

• Kutaja
• Palasam
• Asvakarna
• Paribhadrak
• Bibhitaka
• Aragvadha
• Tilvaka
• Arka
• Snuhi
• Apamarga
• Patala
• Naktamala
• Vrsa
• Kadali
• Citraka
• Putika
• Indravrksa
• Asphota
• Asvamaraka
• Saptachchada
• Agnimantha
• Gunja
• Four kinds of Kosataki

The ash of the above said shall be taken in the quantity of 1 drona (10.24 kg), put and mixed in six drona (61.44kg) of water. If strong alkali is needed, the ash is mixed in the urine of cows etc (instead of water). This ash mixed water shall be filtered through cloth for twenty-one times.
This filtered water is now put in a large iron cauldron and boiled. While boiling, the liquid should be slowly and constantly stirred with a ladle.
During the process of boiling, when the liquid becomes clear, red colored, sharp and slimy, the vessel should be removed from the fire. This should again be filtered through a thick cloth into another (iron) vessel and the filtrate (liquid) should be cooked again. Before heating, one or one and half kudava (160 or 240 grams) of the solution of ash (alkaline water) should be removed and kept separately, stored in a different vessel.
After that, the ash of Katasarkara, Bhasmasarkara (ash of limestone), Ksirapaka (oyster shell) and Sankha Nabhi (conch shell) ate burnt on fire and made red hot and put into iron vessel containing the solution of ash (alkali) and stirred well. Then eight pala (320 grams) of ash of Sankhanabhi etc. are macerated in two drona (20-84 kg) of the same solution (taken out separately as explained earlier), made into paste is also added (as prativapa). Cooking is continued while stirring the contents all through till the mass becomes neither too solid nor too liquid (thin). When the cooking is almost complete, the liquid is then poured into the iron vessel, closed with a lid and preserved carefully. This is the method of preparing Madhyama kshara (alkali of moderate strength and potency).

एषचैवाप्रतीवापःपक्वःसंव्यूहिमोमृदुः॥१२॥

This kshara itself is called by names Samvyuhima kshara or Mrdu kshara, which is an alkali of mild potency. It is prepared without Prativapa – adding other drugs.

प्रतीवापेयथालाभंदन्तीद्रवन्तीचित्रकलाङ्गलीपूतिकप्रवालतालपत्रीबिडसुवर्चिंकाकनकक्षीरीहिङ्गुवचातिविषाःसमाःश्लक्ष्णचूर्णाःप्रतीवापः।सएवसप्रतीवापःपक्वपाक्यस्तीक्ष्णः॥१३॥

In the prativapa of Katasarkaradi herbs, the fine powder of equal quantity of each of Danti, Dravanti, Citraka, Langali, Putikapravala, Tadapatri, Bida lavana, Suvarcika, Kanakaksiri, Vaca and Ativisa – all or as many as available are added in quantity of one sukti (20 grams). In this way if prativapa (adding extra drugs to enhance the properties) of Katasarkara etc is added with prativapa of Danti etc and cooked, it is called as (the resultant alkali) Tiksna kshara (alkali of strong potency). It is also called as Pakya kshara.

तेषांयथाव्याधिबलमुपयोगः॥१४॥
क्षीणबलेतुक्षारोदकमावपेद्वलकरणार्थम्॥१५॥

The two kinds of kshara i.e. mrdu and tiksna should beb used according to the strength of the disease. To enhance the strength of a weak or mild potency alkali, it needs to be soaked in an alkali solution for a short time. This will enhance the strength of the alkali.
kshara guna Dosa- Good Properties and demerits of Caustic Alkali

भवतश्चात्र:-
नैवातितीक्ष्णोनमृदुःशुक्लःश्लक्ष्णोऽथपिच्छिलः
अविष्यन्दीशिवः शीघ्रःक्षारोह्यष्टगुणःस्मृतः॥१६॥
अतिमार्दवश्वैत्योष्णयतैक्ष्णयपैच्छिल्यसर्पिताः।
सान्द्रताऽपक्वताहीनद्रव्यतादोषउच्यते॥१७॥

Kshara Ashta Guna – The eight good properties of alkali are –

1. Naiva Atitiksna – Not very strong,
2. Na Mrduh – not very mild
3. Suklah – white in color
4. Slakshna – smooth
5. Pichchila – slimy
6. Avisyandi – not spreading
7. Siva – good acting
8. Sighrah – quick acting
   kshara Ashta Dosha – The eight demerits of alkali are –
9. Ati mardava – very mild / weak,
10. Ati svaitya – too much white in color
11. Ati ushna – very hot (heat producing)
12. Ati tiksna – highly penetrating
13. Ati pichchila – very slimy
14. Ati sarpitah – greatly spreading
15. Ati sandrata – very thick (liquid
16. Apakvata – not well cooked, and
17. Hina dravyata – lacking in drugs (mentioned in the classics) required to prepare the

Pratisaraniya kshara prayoga: Procedure of Applying caustic Alkali externally

तत्रक्षारसाध्यव्याधिव्याधितमुपवेश्य,निवातातपेदेशेऽसंबाधेऽग्रोपहरणीयोक्तेनविधनेनोपसंभृतसंतसंभारं,ततोऽस्यतमवकाशंनिरीक्ष्यावघृष्यवलिख्यप्रच्छयित्वा,शलाकयाक्षारंप्रतिसारयेत्,दन्त्वावाक्शतमात्रमुपेक्षेत॥१८॥

The patient, who is suffering from a disease which is curable with application of alkali, should be made to sit in a place devoid of breeze and sunlight. The place should be broad (not narrow). All the necessary equipment and things required for conducting kshara karma shall be collected beforehand and kept ready, as explained in agropaharaniya chapter (chapter 5).
Next, in the patient who is fit to undergo kshara Karma, the physician should properly inspect the site or place of the body marked for kshara karma i.e. application of caustic alkali.
Later, he should scrub, scrape or incise the site selected for alkali therapy. Then, holding the kshara in a salaka yantra, which is a specially designed rod like instrument for application of kshara, the physician should smear the alkali over the site of the disease, marked for applying it.
After application of kshara, shata matra kala i.e. time period required for pronouncing one hundred letters should be allowed to elapse, as waiting period i.e. the physician should wait for a timem period of one hundred counts.

Kshara Dagdha Lakshana: Signs of good burning by alkali (cauterization)

तस्मिन्निपतितेव्याधौकृष्णतादग्धक्षणम्।
तत्राम्लवर्गःशमनःसर्पिर्मधुकसंयुतः॥१९॥
The signs of good burning by alkali (cauterization by alkali) are –

• disappearance of the disease following the application of kshara / falling off of the diseased part following the application of kshara and
• development of black color at the site
  Once this appears, the drugs of the ‘sour tasting group – amla varga’ are mixed (processed, boiled) with ghee and powder of madhuka – licorice is applied. This relieves burning sensation, pain and discomfort.

अथचेत्स्थिरमूलत्वात्क्षारदग्धंनशीर्यते।
इदमालेपनंतत्रसमग्रमवचारयेत्॥२०॥
अम्लकाञ्जिकबीजानि तिलान्मधुकमेवच।
प्रवेष्यसमभागानि तेनैनमनुलेपयेत्॥२१॥
तिलकल्कःसमधुकोव्रणरोपणः

If the diseased part (vitiated muscle etc tissues) does not fall off in spite of being burnt by the alkali, the area should be smeared with paste of all the drugs which are mentioned henceforth.
Equal quantities of amla kanjika bija (the solid part settled at the bottom of amla kanjika – sour gruel), sesame and madhuka – licorice should be ground together and the resultant paste be applied on the part burnt by alkali.
For further healing of the ulcer left out after application of the above said formulation, paste of tila – sesame and madhuka – licorice added with ghee is applied at the site.

Amlarasa Karma: Action of the sour taste

तीक्ष्णेनवीर्योष्णेनःचयोजितः॥२२॥
आगेयेनाग्रिनातुल्यःकथंक्षारःप्रशाम्यति।
एवं चेन्मन्यसेवत्स! प्रोच्यमानंनिबोधमे॥२३॥
अम्लवर्ज्यान्रसान्क्षारेसर्वानेवविभावयेत्।
कटुकस्तत्रभूयिष्ठोलवणोऽनुरसस्तथा।
अम्लेनसहसंयुक्तःसतीक्ष्णलवणोरसे॥२४॥
माधुर्यं भजतेऽत्यर्थंतीक्ष्णभावंविमुञ्चति॥
माधुर्याच्छममाप्नोतिवह्निरद्भिरिवाप्लुतः॥२५॥
Lord (Master) Dhanwantari said to Sushruta ‘Dear son, if you opine – how does amla rasa (sour taste) which possesses penetrating property, hot potency and fire like activities, having fire like action, mitigate the effect of kshara – alkali, which also has similar properties as those of fire, then listen to what I am going to say now (my reply)’.
In kshara (alkali), all tastes (sweet, salt, pungent, bitter and astringent) are present, except sour taste.
Among these five tastes, pungent is the predominant taste and salt is the secondary taste. When these pungent and salt tastes combine with the sour taste they become predominantly sweet.
When salt having penetrating quality gets mixed with sour taste it would acquire excessive sweetness and cast off its penetrating quality and also gets subsided by (mitigated) the sweetness, just like the fire subsides when water is poured on it (effects of burning by alkali gets mitigated).

Dagdha Lakshana: Signs of burning (Cauterization)

तत्रसम्यग्दग्धेविकारोपशमोलाघवमनास्त्रवश्च।
हीनदग्धेतोदकण्डुजाड्चानिव्याधिवृद्धिश्च।
अतिद्ग्धेदाहपाकरागस्त्रावाङ्गमर्दक्लमपिपासामूर्छाःस्यूर्मररणंवा॥२६॥
Samyak Dagdha Lakshanas (signs of proper cauterization) –

• mitigation of the diseases (subsiding of symptoms like pain, swelling, bleeding etc),
• feeling of lightness (of the diseased part) and
• stoppage of exudations
  Hina Dagdha Lakshanas (signs of inadequate cauterization) –
• pricking pain,
• itching,
• loss of movement and
• increase of the disease (aggravation of symptoms)
  Ati Dagdha Lakshanas (signs of excessive / over burning) –
• burning sensation,
• suppuration (ulceration),
• redness,
• discharges / exudation,
• pain in the body parts,
• exhaustion,
• severe thirst,
• fainting and
• even death

क्षारदग्धव्रणंतुयथादोषंयथाव्याधिचोपक्रमेत्॥२७॥
The kshara Dagdha Vrana i.e. ulcer which is caused by alkali burn i.e. cauterization, shall be treated according to the aggravated dosha and the disease, suitably.

Kshara Anarha: Contraindications for Alkali Cautery

अथनैतेक्षारकृतया:-तद्यथा-दुर्बलबालस्थविरभीरुसर्वाङ्गशूनोदरिरक्तपित्तिगर्भिण्युतुमतीप्रद्धज्वरिप्रमेहिरुक्षक्षतक्षीणतृष्णामूर्च्छोपद्रुतकलिबापवृत्तोद्वृत्तंफलयोनयः॥२८॥
तथामर्मसिरास्त्रायुसन्धितरुणास्थिसेवनीधमनीगलनाभिनखान्तःशेफःस्त्रोतःस्वल्पमांसेषुचदेशेष्वक्ष्णोश्चनदद्यादन्यत्रवर्त्मरोगात्॥२९॥
Cauterization by Alkali should not be done for persons such as

• the debilitated,
• children,
• old aged,
• fearful,
• those suffering from swelling all over the body, enlargement of the abdomen, bleeding diseases,
• pregnant lady,
• woman during menstruation,
• those in whom the intensity of the fever has abnormally increased (advanced stage of fever),
• those suffering from diabetes, those who are emaciated due to injury to the chest (lungs), thirst, fainting
• those impotent,
• women whose uterus has been displaced downwards or upwards
  So also, alkali shall not be administered in places such as vital spots, veins, ligaments, joints, cartilages, sinews (raphae, sutures), arteries, throat, umbilicus, nail-bed, penis, channels, places of the body with less muscles and eyes, except diseases of the eyelids

तत्रक्षारसाध्येष्वपिव्याधिषुशूनगात्रमस्थिशूलिनमन्नद्वोषिणंह्र्दयसन्धिपीडोपद्रुतंचक्षारोनसाधयति॥३०॥

Even in those diseases which are curable with the use of alkali, administration of kshara (alkali) will not benefit (yield good results) in patients having swelling all over the body, pain in the bones, aversion towards food, pain in the heart and joints.

Limitations of administration of Kshara /Alkali

भवतिचात्र:-
विषाग्रिशस्त्राशनिमृत्युकल्पः क्षारोभवत्यल्पमतिप्रयुक्तः॥
सधीमतासम्यगनुप्रयुक्तोरोगान्निहन्यादचिरेणघोरान॥३१॥

One verse here:-
Alkali (cauterization) administered by a person of poor intelligence will be like (the effect of) poison, fire, sharp weapon, thunderbolt and death. On the contrary, if alkali is administered properly by an intelligent person (physician, surgeon) it can cure even dreadful diseases in quick time.

इतिश्रीसुश्रुतसंहितायांसूत्रस्थानेक्षारपाकविधिर्नामैकादशोऽध्यायः॥११॥

Thus end the Eleventh chapter by name ksharapakavidhi in Sutra Sthana of Susruta Samhita.