SUSHRUTA – OUR PROUD HERITAGE

 

Of late a group of plastic surgeons, historians and inquisitive people are trying to dig into the history and gather some tangible evidence about the life and time of the great sage Sushruta. The fact that he was the ‘father of Plastic Surgery’ and his devised method of reconstructing a cut nose is still practiced today and the world calls it the ‘Indian Rhinoplasty’ is no longer debated. A statue of this great sage has found a proud place in the foyer of the Australian College of Surgeons in Melbourne and many medical institutions in India acknowledge his contribution by putting us his statues and paintings in their premises, a giant one in the garden of Amrita Institute of Medical Sciences in Cochin being the most eye catching.

 

Statue of Sushruta in Australian College of Surgeons, Melbourne.

Sushruta is believed to be the son of a sage Vishwamitra and disciple of guru Divodas or Dhanvantari, the King of Kashi. History dates him to 600 BC-1000BC in the Vedic times, placing him on the time line, a millennium before the Greek physician Hippocrates and two millennia before another Greek, Galen and Roman,Celsius! It is today hard to believe that even as way back as 600BC a man performed complex surgical procedures including reconstruction of the nose by cheek flap, repair of cut earlobe, piercing of earlobe, repair of cut lip and skin grafting with medieval instruments that he himself manufactured. Not only does it say volumes about the quality of medicine being practiced then but also about the quality of metallurgy and engineering which must have coexisted in order to make the variety of instruments which Sushruta had designed after watching closely the beaks of birds and paws and jaws of animals!

 

Sushruta is said to have compiled a monumental thesis in surgery, the ‘Sushruta Samhita’. It is the oldest known surgical text and it describes in exquisite detail the examination, diagnosis, treatment and prognosis of numerous ailments, as well as procedures of plastic surgery, including reconstructive surgery and rhinoplasty. Written in Sanskrit in the form of Shlokas, verses and incantations, gilded by the flowery language and metaphors characteristic to Sushruta, the Samhita was not an easy text to decipher.  It is regarded to be a part of Atharva Veda and the access to the Vedic knowledge was restricted to select few scholars of the ancient times. Such social factors may have contributed to the lack of dissemination of this ancient knowledge in India leading ultimately to our dependence on the Western world for our surgical know-how. The ancient Indian medical practitioners were divided into two classes: the Salya-cikitsakas (surgeons) and the Kaya-cikitsakas (physicians) but for a surgeon the knowledge of both the fields was essential.

 

The original manuscript of Sushruta Samhita was lost over time and the present text is a revised version by the Buddhist scholar Vasubandhu in circa AD 360-350. Following the Arabic trade route, in eighth century A.D, 'Sushruta Samhita' was translated into Arabic as Kitab-Shaw Shoon-a-Hindi and Kitab-i-Susrud, by the orders of Caliph Mansur in the 8^th century. The Bower Manuscript is a Sanskrit-language manuscript written in the Brahmi Script on birch bark. Lieutenant H. Bower discovered the manuscript in 1890, from Kuchar, Eastern Turkestan and sent it to Colonel J. Waterhouse, the President of Asiatic Society of Bengal. Subsequently, Augustus Hoernle deciphered the manuscript. The first European translation of 'Sushruta Samhita' was published by Hessler in Latin and by Muller into German by Vellurs in the early 19th century and into English by Hoernle. The first complete English translation was done by Kaviraj Kunja Lal Bhishagratna in 1907 at Calcutta, in three volumes, and a later edition came out in 1963. It is argued whether Sushruta is a single person or if the Samhita is actually a compendium with multiple contributors, members of the gurukul of Sushruta. The followers of Sushruta were in fact called as 'Saushrutas'.

 

Sushruta Samhita is a collection of surgical and allied knowledge, written in two parts, the Purva-tantra and Uttara-tantra. Purva-tantra has 120 chapters in five sections - Sutra-sthana, Sarira-sthana, Nidana-sthana, Chikitsa-sthana and Kalpa-sthana. The Chikitsa-sthana deals with surgical conditions including obstetrical emergencies, geriatrics and aphrodisiacs. The Kalpa sthana contains visha tantra which describes the nature of poisons and their management. Uttara-tantra covers Salakya, Kaya-chikitsa, Kaumarabhetya and Bhutavidya and  Aupadravika, the description of many complications of surgical procedures like hiccough, fever, krmiroga, pandu, dysentery, cough, kamala, etc. The Salakyatantra has description of the various diseases of eye, ear, nose and head. The two parts together cover, apart from surgery, other specialities like medicine, paediatrics, geriatrics, diseases of the ear, nose, throat and eye, toxicology and psychiatry. The Sushruta Samhita describes over 300 surgical procedures and classifies human surgery  under eight heads - Chedya (excision), Lekhya (scarification), Vedhya (puncturing), Esya (exploration), Ahrya (extraction), Vsraya (evacuation) and Sivya (Suturing). There are detailed descriptions on methods of haemostasis and leech therapy.

 

The Sushruta Samhita thus is a comprehensive surgical textbook describing in detail general surgical techniques of making incisions, probing, extracting of foreign bodies, alkali and thermal cauterisation, tooth extraction, excision, the use of trocars to drain abscess, hydrocele and ascitic fluid, methods to stitch the intestines using ant-heads as stitching material, more complex procedures including removal of the prostate gland, urethral stricture dilatation, extraction of urinary bladder stone, hernia surgery, Caesarean section, management of hemorrhoids, fistulae, laparotomy and the management of intestinal obstruction, perforated intestine and accidental perforation of the abdomen with protrusion of omentum. Orthopaedic surgery including management of dislocation of joints (sandhimukta) and fractures of the shaft (kanda-bhagna) bones and their reaction to the injuries, principles of fracture management, viz., traction, manipulation, appositions and stabilization including some measures of rehabilitation and fitting of prosthetics are all described. Ophthalmic surgery for various eye diseases, medical or surgical interventions including cataract surgery have also found a place in it. It also deals with dissection and the study of the anatomy of the human body, and even embryology and sequential development of the structures of the foetus!

 

Incision making, wound care and wound closure all find their due place in Sushruta Samhita. ‘Chedan Karma’ (Incision), according  to Sushruta are mainly of three types - on head, eyelid, cheek, frontal region, lips, gums, axilla, hip joint - ‘Triyaka cheda’ means oblique incision, over upper and lower limb - ‘Chandramandal’ incision (Circular) and over anal region and penis incision should be ‘Ardhchandrakruti’ (Semicircular). He further went on to mention that if these rules of incision were not followed there were chances of injuring vital structures, delayed wound healing (Chirad Vranasanroho) and formation of keloid (Mamsakandi). Also while describing incision on breast abscess (StanaVidradhi) Sushruta has mentioned that incision should be taken such that it should avoid Papillary duct and areola otherwise there are chance of formation of sinus (Nandivrama).

 

While describing wound management (vrana-chikitsa) Sushruta has described sixty types of treatment (Shashthiupokrama). Interestingly, wound scrapping (lekhana) is mentioned as sixteenth upakrama. Thereafter before suturing wound should be thoroughly cleaned otherwise there will be chances of pus formation in wound. He mentioned that wounds with hard fatty mass should be scrapped. Scrapping should be such that edges of wound should be at equal level (Vartmanamtupramanenasamam).  Thereafter before suturing wound should be thoroughly cleaned otherwise there will be chances of pus formation in wound. In Shashitiuparamas (Sixty methods) he described sixty types of treatments for different types of wounds and their treatments - Nirvapan, Vtkarika, Utsadan and Avasadan  being a few treatments for large wound. The basic principles of wound care still remain the same even after so many years!

 

Sushruta has given detailed description of various techniques of wound closure. He mentioned four types of suturing - Vellitaka, Gofanika, Tunnasevani, Rujugranthi which should be used for different parts of body.  He has also mentioned different types of needles to be used to different areas for wound closure. For areas which is less fatty in nature and over joints, round body two finger long needle (Vrultanguladwgyam) should be used while in areas with more fats - cutting body, three finger long triangular (Ayata tryangula tryastra) needle should be used and in areas where vital organs are nearby curved (Dhanurvakra) needle should be used.

 

Treatment was not confined to surgery alone but there are descriptions on comprehensive perioperative care. Sushruta remarks: "the patient who has been fed, does not faint, and he who is rendered intoxicated, does not feel the pain of the operation." There is evidence of usage of wine and cannabis incense for inducing anaesthesia before surgery. So Sushruta can be safely considered to be ‘the father of Anaesthesiology’ as well!

 

His "paschat-karman" or post-operative schedule included the scar management protocols, rehabilitation and removal of complications. Fourteen types of bandaging capable of covering almost all the regions of the body and different methods of dressings with various medicaments are mentioned in Sushruta Samhita. Evidence points to a knowledge of Medhumeha (diabetes) and other co morbid conditions that can influence surgery!

 

Sushruta did not limit his teachings to procedures; he also described surgical instruments, catheters, sounds and irrigating syringes. He gave details of their manufacture (including the metal to be used and the measurements) and maintenance (cleaning by caustics and alkalis).

Surgical instruments mentioned in Sushruta Samhita.

 

Sushruta had realized the importance of balance in knowledge and skill. In the Samhita he mentions, "a physician, well-versed in the principles of science of medicine but incompetent in his art because of want of practice, as well as the physician, experienced in his art but short on the knowledge of Ayurveda, is like a one-winged bird that is incapable of soaring high in the sky". A new student of surgery was expected to study for at least 6 years, after taking a solemn oath, much akin to the Hippocratic oath. He made his disciples practice their surgical skills on various experimental models, like incising on watermelon, gourd, clay pots and reeds, probing on worm eaten wood, just like in present day simulation skills workshops. Sushruta insisted on a sound knowledge of anatomy (Sharirasthana) and embryology in surgical practise and studies were conducted on decomposing cadavers and dead foetuses towards this aim.

 

Apart from his surgical prowess, Sushruta was also a staunch proponent of good ethics, attitude and communication skills in surgical aspirants. According to him, "He is a good surgeon, who possesses courage and presence of mind, a hand free from perspiration, tremor-less grip of sharp and good instruments and who carries his operations to success and the advantage of his patient who has entrusted his life to the surgeon. The surgeon should respect this absolute surrender and treat his patient as his own son." Sushruta laid down the pre requisites for a qualifying surgeon as ”A physician who has set out on this path should have witnessed operations. He must be licensed by the king. He should be clean and keep his nails and hair short. He should be cheerful, well-spoken and honest". He warns that improper intervention with surgical manoeuvre due either to ignorance of the progress of the disease process, greed for money or lack of judgment, lead only to complications. With such high standards set by the master surgeon and teacher, this era was regarded as the golden age of surgery in ancient India.

              

Sushruta remains our proud heritage and Sushruta Samhita is a living testament to his outstanding brilliance and colossal contribution to the science and art of healing. It is a pity that despite knowing a fair bit about this sage, teacher and exponent of surgical practice, there are still gaps in our trail of knowledge which only tangible evidence would be able to fill. Let us try to fill these missing gaps.  I also invite you to watch a movie which the Association of Plastic Surgeons of India produced on Sushruta:

https://www.youtube.com/watch?v=rCFtR92JS-c