Literary and Analytical Study of the Source Plants of Kshara (Alkali) for Ksharasutra Preparation in the Management of Fistula-in-ano

The different surgical techniques and importance in disease treatment were explored by Sushruta, the father of surgery. Furthermore, Anushastra or parasurgical substances and methods from Ayurveda are distinctive in surgical fields as discovered by Sushruta. Kshara or alkali are useful for performing excision/removal, incision/cutting, scraping, alleviating three Doshas and several special procedures, and therefore superior to Shastra (sharp instruments) or Anu Shastra (accessory apparatuses). Also, Kshara is derived from diverse Ayurveda plants and applied in different ways to manage various diseases, including bhagandara (fistula-in-ano) and other numerous anorectal conditions. This study implemented a literary analysis of the plant sources employed to prepare Kshara sutra. There are 23 Kshara source plants provided by Sushruta. The specimens were identified by a comparison of the description to previously published Kshara sutra references. The data recorded encompassed botanical name, local label, location, pharmacodynamics, morphology characteristics, action, chemical constituents, and antimicrobial activity. There are three source plants provided by Sushruta to prepare Kshara sutra for fistula-in-ano management in this study including Curcuma longa Linn., Commiphora mukul, and Euphorbia antiquorum. It is possible to become a reference for Kshara sutra, a novel drug delivery system in Ayurvedic surgery for anorectal diseases and involves a thread smeared with kshara (alkali) applied to induce both mechanical and chemical cutting and healing.


INTRODUCTION
The different surgical techniques and importance in disease treatment were explored by Sushruta, the father of surgery. Furthermore, Anushastra or parasurgical substances from Ayurveda are distinctive in surgical fields as discovered by Sushruta. Anushastra refers to any substance or procedure capable of use as surgical instruments with minimized invasion and stress on the patients, and is known as hinashastra or shastra sadrushya (Acharya & Acharya, 2008;Lobo et al., 2012).
Importance of Kshara. According to Susruta Samhita, Kshara or alkali is useful to perform excision/removal, incision/cutting, scraping, alleviation of three Doshas, for various special procedures, and therefore superior to Shastra (sharp instruments) and Anu Shastra (accessory apparatuses) (Ammon & Wahl, 1991). Ashtanga Hridaya Samhita posits Kshara is the best of all the sharp equipment, usable in inaccessible places, and performs many functions including incising and excising. Also, this substance is successfully used for difficult to cure diseases, and is capable of application in form of a drink (Banerjee & Nigam, 1977). Therefore, Kshara or alkali substances are considered one of the most important parasurgical methods.
Kshara is obtained from different Ayurveda plants and applied in diverse ways to manage several diseases, including bhagandara (fistula-in-ano) and other ano-rectal conditions. Ksharasutra, a novel drug delivery system, is commonly used for Ayurvedic surgery in anorectal diseases and involves a thread smeared with kshara applied to induce both mechanical and chemical cutting and healing. Furthermore, Sushruta describes an exhaustive list of Kshara source plants, and Kshara of Achyranthes aspera is majorly applied in Ksharasustra preparation. However, different Kshara source plants are suited for individual patients due to the diverse exerted pharmacological behaviour, and therefore, the Prakriti (constitution) of the patients and dosha involvement in the clinical conditions is different.
Types of kshara. Sushruta classified Kshara into two types: Pratisaraniya Kshara and Paaniya Kshara, for external application and internal use respectively.
This study implemented a literary analysis of three plant sources used to prepare Kshara sutra for the management of fistula-in-ano.

MATERIALS AND METHODS
The specimens were identified by a comparison of the description to previously published Kshara sutra references. The data recorded encompassed botanical name, local label, location, pharmacodynamics, morphology characteristics, action, chemical constituents, and antimicrobial activity.

RESULTS AND DISCUSSION
The result indicated both Kshara types possess individual indications and precautions, and ksharasutra application resulted in a modified form of Pratisaraniya kshara. Table  1 shows there are 23 list of Kshara source plants provided by Sushruta, while Table 2 further divides this according to the doshas.
The textual description of the plants shows Kshara dravya potential, with individual Rasapanchaka. Therefore, the resulting Kshara is likely to possess diverse set of pharmacological properties and effects, and this causes application in several patients to reduce regular undesirable effects including pain, burning, itching, without affecting the primary aim of fistula-in-ano management.

Indications of Three Kinds of Alkali.
Teekshna Kshara -The strong potency alkali is useful for treatment of diseases arising from Vata, Kapha, Medas (fat) Arbuda (cancerous growth) and ailments with high curing difficulty. Madhyama Kshara -The medium potency alkali is effective in moderate strength diseases with ease in curing. Mrudu Kshara -The mild alkali is applied for in diseases occurring from Pitta, Asra-Rakta and hemorrhoids.
Source plants of Kshara sutra preparation.  raktashodhaka, raktavardhaka, shothahara, kaphanissaraka, mutrala, ashmarihara, svedajanaka, kandughna, katupaushtika, vedanasthpaka, vishaghna, vranashodhaka, raktarodhaka, shirovirecana, medohara, lekhana, vatakaphaghna, arshoghna. Morphology. Achyranthes aspera is an erect or procumbent annual or perennial herb with height of about 1-2 meter, and occasionally a woody base. The stems are angular, ribbed, simple or branched from the base, often with tinged purple colour, while the branches are terete, totally quadrangular, striate or pubescent. Also, the leaves are thick, 3.8-6.3 × 22.5-4.5 cm in ovate-elliptic or obovate-round shapes, finely and softly pubescent on both sides, with entire petiolate or petiole 6-20 mm length. The flowers are greenish white, and numerous axillary or terminal spikes were about 75 cm long. The seeds are subcylindric, truncate at the apex, rounded at the base and reddish brown. Chemical constituents. The content of the leaves, stems and roots were alkaloids, sterol and saponins. Furthermore, the root possess ecdysone, ecdysterone (polypodine A) and insect moulting hormones while the seeds contain saponin A&B. The fruit comprises two oleanolic acid based saponins. Also, the plant encompasses an alkaloid achyranthine (betaine), amino acids, arginine, histidine, lysine, cystine, threonine, methionine, lucine, isolucine, phenylalanine, tryptophan and carbohydrate, valine, α-rhamnopyranosyl, ß-D gluuronopyranosyl, ß-D galactopyranosyl, galactose, xylose, rhamnose and glucose, large amount of potash, hormones, ecdysterone and inokosterone. Antimicrobial Activity. Khan et al. (2010) reported an indication of mild to moderate antibiotic activity against B. subtilis, E. coli and P. aeruginosa in the ethanol and chloroform extracts of Achyranthes aspera seeds. The studies of Prasad et al. (2016) revealed antimicrobial action from the various extracts of the plant leaves and callus. Misra et al.

Achyranthes aspera
(1992) discovered 17-pentatriacontanol was a major constituent isolated from essential oil of the plants sprouts, and showed antifungal activity against Asperigillus carneus (Prasad et al., 2016). Antibacterial and antifungal effect against various pathogenic strains including E. coli, P. aeruginosa, Citrobacter sp., B. subtilis, Micrococcus sp., Klebsiella sp. using disk diffusion and well-plate method (Malarvili & Gomathi, 2009;Manjula et al., 2009;Samaranayake et al., 2020). The extracts indicated maximum inhibition of E. coli (17 mm), followed by species of Pseudomonas (14 mm), Citrobacter (12 mm), Bacillus (12 mm) and Micrococcus (12 mm). Also, predominant prevention from gram negative bacteria at a higher concentration of 50µg/ml was displayed (Saravanan et al., 2008). Antioxidant Activity. Tahiliani & Kar (2000) researched several leaves extracts for antioxidant effect, and Gayathri et al. (2009) found this in the leaves and roots while Malarvili & Gomathi (2009) reported this in seeds. Therefore, the presence of phytoactive constituents is found in Achyranthes aspera (Sharma, 1977). The phytoactive component caused reduction in lipid peroxidation rate, and enhancement in free radical scavenging activity of the herbal seed powder. Wound Healing Activity. Edwin et al. (2008) explored the ethanolic and aqueous extracts of the leaves for injury healing potential, using two wound models comprising excision and incision.

Curcuma longa Linn.
Family. Scitaminaceae Sanskrit names. Haridra, Nisha Pharmacodynamics. Rasa-Tikta, Katu,Guna-Ruksa, Laghu, Virya-Ushna, Vipaka-Katu, Dosha karma-Kapha-vatashamaka, Pittarechaka-shamaka Actions (Karma). Vamya,Krimighna,tvachya, mukhakantikara, dehavarnaprada, kushtaghna, kandughnakasaghna, vedanasthapana, shothahara, raktaprasadhaka, raktastamhaka, vranaropana, vranashodhana, lekhana, mustrasangrahaniya, mutravirajaniya, garbhashayashodhana, stanyashodhana, shukrasodhana, hikkanigrahana, anulomana, arshoghna, tvakdoshahara. Morphology. A tall herb with large rootstalk, ovoid in shape and possessing sessile cylindrical tubers colored orange inside. Furthermore, the leaves are very large with tufts length of 1.2 meters or more, including the petiole with similar measurement as the blade, oblong-lanceolate, and tapering to the base. The flowers had autumnal spikes of 10-15 cm length, peduncle of 15 cm or more, concealed by the sheathing petiole while the flowering bracts were pale green and the coma tinged with pink. Pharmacology. Curcumin (I, II, III) is a major component in Curcuma longa, and responsible for the biological actions. Furthermore, this exhibits anti-parasitic, anti-spasmodic, antiinflammatory and gastro-intestinal effects in vitro, and constrains carcinogenesis and cancer growth in parental and oral application on animal models. According to Araújo & Leon (2001), the extraction of dried powder with 95% ethanol yielded cured ethanol extract of 29.52% (w/w) containing curcumin (11.6%), demothxycurcumin (10.32%), and bisdemothxycurcumin. The agar disc diffusion method was employed to test this for antifungal effect against 29 clinical strains of dermatophytes, and an inhibition zone range of 6.1 to 26.0 mm was found. Wuthi-Udomlert et al. (2000) discovered improved cutaneous wound healing in rats and guinea pigs by curcumin (diferuloymethane), a natural product derived from C. longa rhizomes. Also, the animal injuries treated with oral and tropical curcumin in diabetic model indicated timelier re-epithelialisation, improved neovascularisation, enhanced migration of several cells including dermal myo-fibroblasts and macrophages into the wound bed, and a higher collagen content (Sidhu et al., 1999). Furthermore, the popular ability of the transforming growth factor beta 1 to enhance wound healing is likely due to curcumin.

CONCLUSION
There are three source plants provided by Sushruta to prepare Kshara sutra for fistula-in-ano management in this study including Curcuma longa Linn., Commiphora mukul, and Euphorbia antiquorum.