SUSRUTA

          In 1793, A Maratha Vaidya reconstructed
          the nose of a cart-driver.Illustration from
          Gentleman's Magzine (London), Oct. 1794

In 1670, when war broke out between the Mughals and the Aadilshah of Bijapur, some Mughal soldiers committed depredations in the Bijapur villages. They were captured and, as a punishment, their noses were cut off. However, after some days all of them received new noses. How ? Describing the treatment of the native surgeons, Niccolao Manucci, the Italian traveller who was in India in those days, says :

"The surgeons belonging to the country cut the skin of the forehead above the eyebrows, and made it fall down over the wounds on the nose. Then, giving a twist so that a live flesh might meet the other live surface, by healing applications, they fashioned for them other imperfect noses. There is left above, between the eyebrows, a small hole, caused by the twist given to the skin to bring the two live surfaces together. In a short time the wounds heal up, some obstacle being placed beneath to allow of respiration. I saw many persons with such noses, and they were not so disfigured as they would have been without any nose at all." (Storia do Mogor or Mogul India, 1653-1708 AD).

This is, perhaps, the earliest description of Indian plastic surgery of the nose given by an European. About a hundred years later, a detailed description of the same technique is obtained from the following episode.

From 1769 AD to 1799 AD, in a period of thirty years, four Mysore Wars were fought between Hyder Ali plus his son Tipu Sultan and the British. As a result of these wars the British learnt two very important Indian techniques – rocketry and plastic surgery. Both these Indian techniques were further improved – first in England and then in other European countries. How the British learnt the art of Indian plastic surgery is a fascinating story.

A Maratha cart-driver, Kawasaji, who had served the British, and four Tilanges (Indian soldiers of British army) had fallen into the hands of the Sultan of Srirangapattanam. Their noses and right arms were cut off as a punishment for serving the enemy. Then they were sent back to the English command.

After some days, when dealing with an Indian merchant, the English commanding officer noticed that he had a peculiar nose and scar on his forehead. On inquiry, he learnt that the merchant's nose had been cut off as a punishment for adultery and that he had a substitute nose made by a Maratha Vaidya of the kumhara (potter) caste. The commanding officer sent for the Vaidya and asked him to reconstruct the nose of Kawasaji and others.

The operation was performed near Pune in the presence of two English doctors. An illustrated account of this operation appeared in the Madras Gazette. Subsequently, the article was reproduced in the Gentleman's Magazine of London in October 1794. This description fired the imagination of the young English surgeon J.C. Carpue, who after gathering more information on the "Indian nose", performed two similar operations in 1814 AD with successful results. After this, plastic surgery became popular throughout Europe. All replacement operations which use flaps of skin in the immediate vicinity of the loss are known as 'Indian plastic surgery'.

In ancient Europe there was no tradition of plastic operations. Genuine records of plastic operations are not found in Europe until the middle of the fifteenth century. These came from Italy. Many European scholars are of the opinion that reports of Indian plastic operations reached Italy by way of seamen and merchants. From Italy we have the record that in 1442 AD, Branca, a surgeon of Sicily, carried out plastic operations of the nose, using flap from the face. This operation by Branca was very similar to the one described in the Susruta- Samhita, an Ayurvedic compendium composed in the early centuries of the Christian era. In fact, Susruta-Samhita is the oldest known work that vividly describes the plastic operations of the nose, ear and lip.

The Susruta-Samhita (i.e., Susruta's compendium) pays special attention to surgery. The work primarily deals with salya and salakya, two of the eight divisions of ayurveda, the 'knowledge of longevity'. As defined in the Susruta-Samhita (SS), salya treats of the extraction of arrows and other foreign bodies from wounds caused by them. It also teaches the use of blunt instruments, cutting instruments, caustic and cautery, together with the diagnosis and treatment of inflammation. Salkya treats of diseases of the ears, eyes, mouth, nose, and other parts of the body above the clavicle. Thus, the SS is our most important source of information on surgery in ancient India.

          Dhanvantari:The mythical
          Hindu God of Surgeri

The SS, composed in Sanskrit verse and prose, is divided into five sections (sthanas) comprising 120 chapters, besides the appendix, Uttaratantra, which contains 66 chapters. The SS legend about the origin of šyurveda is almost the same as given in the Caraka-Samhita (CS). In the CS legend, Indra is said to have taught Ayurveda toRsi  Bharadwaja, who taught it to Atreya Punarvasu, the founder of the therapeutic (Kayacikitsa) school of šyurvedic medicine. According to the SS legend, Indra taught the šyurveda to Dhanvantari appearing in the form of Divodasa, the king of KasiI. At last, Divodasa-Dhanvantari, on being requested by a group of pupils consisting of Aupadhenava, Vaitarana Aurabhra, Pauskalavata, Karavirya, Gopuraraksita, Susruta and others, imparts the knowledge of Ayurveda to men. Thus, Divodasa-Dhanvantari is the preceptor and Susruta ("one who has listened to good things") the main receptor.

This partly distinct tradition of the SS shows that the Dhanvantari school of Ayurvedic medicine (surgery) had come into existence long before the composition of the SS. That the Dhanvantari or Susruta school specialised in surgical treatment is also evident from the fact that the Caraka-Saˆhita in some special cases refers back to the specialists called 'Dhanvantariyas'.

The god Dhanvantari is nowhere mentioned in the Vedas; he is a later creation of the epic and puranic mythology. According to the epic legends, at the time of the churning of the ocean by the devas and asuras, Dhanvantari emerged out of the waves carrying amrta or the elixir of life. Some legends link him with the Kasi dynasty of kings, particularly with King Divodasa. Thus, we can safely regard Dhanvantari as a mythical figure. As to the historicity of king Divodasa of Kasi Dhanvantari's human form, we have no definite evidence. Divodasa Atithigva, one of the leading kings of the early Vedic age, is mentioned several times in the Rgveda. But he cannot possibly be identified with the KasiI king Divodasa of later period. The katriya kings, engaged in wars, were more concerned with the treatment of surgery, and therefore king Divodasa of Kasi  might be regarded as the founder of the Varanasi school of surgery, whereas Atreya Punarvasu was the founder of the Taksasila school of therapeutics (kayacikitsa). Susruta, the pupil of Divodasa, might be a historical figure, but we have no material to prove it authoritatively.

Like the CS, the SS is also not the work of a single author. Dalhanacarya (12th century AD), the commentator of the SS, affirms that Nagarjuna has been the 'reconsructor' of the compendium, but does not offer any other information about him. According to some scholars, Nagarjuna was also the author of the Uttaratantra, the appendix or the last section of the SS. There are a number of Buddhist words (e.g., Bhiksu-sanghati or the upper cloth worn by a Buddhist monk) in the SS, which show that the work is definitely of the post-Buddha period.

As to the time and life of Nagarjuna, there is lot of confusion. The Buddhist philosopher Nagarjuna most probably belonged to the second century AD. The Chinese traveller Hiuen-tsang (Yuan Chwang), who lived in India in the first half of the seventh century AD, states that Nagarjuna was a contemporary of the Satavahanas and a master in the science of alchemy. Also, there was at least one more Buddhist Nagarjuna, the author of Rasaratnakara, an alchemical work of the seventh century AD. Thus, it is very difficult to decide as to which Nagarjuna was the real 'reconstructor' of the SS. The present SS seems to have been composed in the early Christian era.

Ayurveda, from ancient times, had been divided into eight branches (ASTANGA) of medical knowledge. Like the CS, the SS also enumerates the eight branches, though in a slightly different order, as below :

(1) Salyatantra – surgery; its various types, and the knowledge necessary for surgical treatment.

(2) Salakyatantra – treatment of diseases of the eyes, ears, nose, throat, and teeth.

(3) Kayacikitsa – therapeutics.

(4) Bhtavidya – psychiatry and psychotherapy.

(5) Kaumarabhrtya– paediatrics.

(6) Agadatantra – toxicology and treatment of poisoning.

(7) Rasayanatantra – treatment of longevity and rejuvenation.

(8) Vajikaranatantra– treatment for increasing virility.

The SS deals with several branches of Ayurveda, but in it the place of honour is given to surgery. The SS itself states that surgery is the most ancient and honoured branch of the Ayurveda, and capable of effecting immediate cure of diseases amenable to it.

The SS, as stated earlier, is divided into six sections, including the so-called appendix. They are :

(1) Sutrasthana (46 chapters) deals with basic doctrines, surgical instruments, procedure for surgical and allied therapies, training methods, duties of the army surgeon, evolution, classification of diseases, properties of different foods and characteristics of drugs, etc.

(2) Nidanasthana (16 chapters) deals with pathology of surgical diseases, such as fistula, chronic skin, urinary tract, abdominal swelling, genital diseases, diseases of the oral tract, dental diseases, etc.

(3) Sarirasthana (10 chapters) describes cosmic origin of life, embryology and anatomy with special emphasis on organs of surgical importance, the vascular system and bodily fluids, care of the expectant mother and the new born child, etc.

(4) Cikitsasthana (40 chapters) deals with treatment of surgical diseases, rejuvenation, therapies like emeses, purgation, enema, inhalation, nasal medication, mouth gargles, etc.

(5) Kalpasthana (8 chapters) deals mainly with toxicology (agadatantra). It describes poisoning of foods and drinks, vegetable and mineral poisons, animal poisons, snake venom, snake bites, rabies, insect poisons and their treatment.

(6) Uttaratantra (66 chapters), the biggest section of the SS, is believed to have been added to the original text by the redactor Nagarjuna. It deals with eye and eye diseases, diseases of ear, diseases of nasal passage, catarrhal conditions, diseases of the head, diseases of female organs, various kinds of fever, malignant tumours, heart diseases, jaundices, haemorrhage, epileptic fits, hiccup, asthma, insanity, hygienic rules, etc.

Thus, the SS is a comprehensive treatise dealing will all the eight branches of Ayurveda, with its greater portion devoted to surgery (Salyatantra andSalakyatantra.

Being basically a surgical work, the SS lays more stress on the practical training of a physician. Susruta insists that the enormous amount of oral learning should be balanced by practical efficiency. "He who is only trained in theory but is not experienced in practice knows not what he should do when he has a patient and behaves as foolishly as a youth upon a battle field. On the other hand, a physician who is educated practically but not in theory, will not earn the respect of better men." (SS. 1.9)

At another place Susruta says : "He who has observed the internal mechanism of the human body, is well read in the works bearing on these subjects and has thus all his doubts expelled from his mind is alone qualified in the science of Ayurveda and has a rightful claim to practice the art of healing." Quacks and charlatans were regarded fit to be killed by the king. Whereas the Caraka school admitted only those pupils who belonged to the Dvija (Brahmana, Ksatriya and Vaisya) castes, the Susruta school, besides these, also admitted pupils from good Sudra families. As it was necessary for Ayurvedic surgeons to dissect and examine dead bodies, they might have sought the help of Sudras and therefore had to admit them in their profession. Even in medieval Europe the anatomists did not always dissect the corpses themselves; the actual dissection was carried out by their assistants.

In the SS, at the end of the fifth chapter of the third section (Sarirasthana) we come across a unique record of dissection of a dead human body. Before describing the actual procedure, Susruta states :"Without the knowledge of Salya (i.e., surgery) no decision can be arrived at on any part of the body whatever, including its skin. Therefore, anyone who strives after acquiring a safe knowledge of Salya, must prepare a dead body, and examine its parts in the right way. Here Salya means actually "anything causing pain" or as a branch of medicine, "the extraction of splinters or extraneous substances" which was the main objective of ancient Indian surgery.

Then follows the actual description of the process of dissection :

"For this purpose one should select a complete human body, which has been neither affected by poison, nor afflicted by a long disease, of a man whose age was not too high. Having removed all that which fills out the entrails, the body should be wrapped in muja, valkala, kusa, sana or any other plant like these and, placed in a cage, it should be fastened in a river with no strong current, and in a hidden spot. There it should be let to decompose. Then, after a period of seven nights, when the body had decomposed in the right way, it should be taken out and rubbed, by slow degrees, with a whisk or anything like that, made of grass-roots or hair or bamboo. And, at the same time, every part of the body, be it great or small, external or internal, beginning with skin, all should be examined with the eye in due succession, as it becomes disclosed in the course of the process of rubbing." (SS. 5.5.49)

The most important point to note here is that the dissection was performed without the use of knife. Because of the horror of corpses and the limited knowledge of anatomy in ancient India, many writers regard this description as untrue or later addition and treat it briefly and in a rather mysterious way. But we must note that the way it is described in the SS, it cannot be imaginary. Nowhere else in the ancient world we find the account of such dissection performed without the use of knife.

We know that in India a dead human body is regarded as impure and frightening. Then, from what source were the perfect dead human bodies obtained? In ancient India most of the dead bodies were either cremated or buried, but not all dead bodies. From several ancient records we learn that many dead bodies were thrown into rivers or heaped in the smasanas without being cremated or buried. This is evident from the Vetalapacavisatika stories where king Trivikramasena is shown using corpses for his adventures. With the help of candalas or svapakas, whose duty it was to handle the corpses, the Susruta school of surgeons might have procured some corpses for the type of dissection described above.

The sort of dissection described in the SS might have been performed partly for acquiring some anatomical knowledge and mainly for discovering the various marmas (junctions of ligaments, veins, muscles, bones or bone-joints) of the human body, because it was believed that a person injured in any of the marmas dies shortly. The SS enumerates 107 marmas and classifies them into five groups, and says that the proper knowledge of the marmas covers half the scope of salyatantra (surgery).

The SS describes two kinds of surgical instruments : blunt (yantra) and sharp (sastra). The blunt instruments number 101, and according to their shape have been divided into six groups, namely :

(I) Svastika or cruciform instruments 24 kinds

(II) Sandamsa or pincher-like " 2 kinds

(III) Tala or picklock-like " 2 "

(IV) Nadi or tubular or hollow " 20 "

(V)Salaka or rod or pricker-like " 28 "

(VI) Upayantra or accessory " 25 "

The cutting or sharp instruments (sastra) are 20 and were made of good iron. The names of some of the sharp instruments are : Mandalagra (round headed knife), Vrddhipatra (a kind of razor), Nakhasastra (nail-parer), Mudrika (finger-knife), suci (needles), Utpalapatra (a knife resembling the petal of a lotus), etc. Susruta also advised the use of some anusastras (substitutes for cutting instruments) in case of infants or when the proper instruments are not available. They are : bamboo, crystal, glass, hair, nails, etc. Besides these, caustic and cautery (agnikarma) were also practised. For blood-letting the use of leeches was quite common. Inflammation was treated with various pastes. We also find a good account of treatment of fractures and dislocations. Susruta also describes the operations of Laparotomy and lithotomy, and 14 varieties of bandages (bandha).

However, it is in the field of plastic surgery of the ear, nose and lip that the surgeons of ancient India greatly excelled. Susruta has described 15 methods of cut-up ear-lobes. In describing the method of rhinoplasty (nasikasandhana) Susruta says:

"The portion of the nose to be covered should be first measured with a leaf. Then a piece of skin of the required size should be dissected from the living skin of the cheek, and turned back to cover the nose, keeping a small pedicle attached to the cheek. The part of the nose to which the skin is to be attached should be made raw by cutting the nasal stump with a knife. The physician then should place the skin on the nose and stitch the two parts swiftly, keeping the skin properly elevated by inserting two tubes of eranda (the castor-oil plant) in the position of the nostrils, so that the new nose gets proper shape. The skin thus properly adjusted, it should then be sprinkled with a powder of liquorice, red sandal-wood and barberry plant. Finally, it should be covered with cotton, and clean sesame oil should be constantly applied. When the skin has united and granulated, if the nose is too short or too long, the middle of the flap should be divided and an endeavour made to enlarge or shorten it." (SS. 1.16).

This was exactly the method followed by the Mara˜tha Vaidya of the kumhar caste when he reconstructed the nose of the cart-driver Kawasaji and others in 1793 AD. Susruta also mentions the reconstruction of the broken lip and the hare-lip (ost˜hasandhana).

The SS classifies surgical operations into eight different kinds: (1) excision (bhedya); (2) incision (chedya); (3) scarification (lekhya); (4) puncture (vedhya); (5) probing (esya); (6) extraction (aharya); (7) drainage or evacuation of fluids (visravya); and (8) suturing (sivya). It is a matter of speculation as to how, in the absence of anaesthetics, the Indian surgeons carried out their major operations. Susruta lays down that "wine should be used before operation to produce insensibility to pain." He again remarks : "The patient who has been fed, does not faint, and he who is rendered intoxicated, does not feel the pain of the operation."

The appendix of the SS, Uttaratantra, deals mainly with ophthalmology, and appears to be a work of a different author. Dalhana the commentator of the SS, says that several physicians had composed works on Salakyatantra (treatment of the parts above the clavicle), one of them being Nimi, the king of Videha. Nimi is also quoted in the Navan…taka, a medical treatise forming parts of the Bower Manuscripts discovered in Chinese Turkistan. Therefore, the Uttaratantra might be the work of Nimi, the specialist in Salakyatantra.

The Uttaratantra describes 76 eye-diseases distributed as follows : nine are confined to the sandhi ; twenty-one to the eye-lids; eleven to the sclerotic; four to the cornea; seventeen to the entire eye-ball, twelve to drsti(pupil, lens, etc.); two are due to external causes and are very painful. The Uttaratantra also gives a description of the operation of cataract.

For centuries the Samhitas of Caraka and Susruta were regarded as standard treatise of Ayurvedic medicine. Their fame travelled far and wide beyond the borders of India. During the reign of the Abbasid Caliph Harun al-Rashid (786-809 AD) an Indian physician, whose name is given as Manka, became the director of the Baghdad hospital and was "successful in curing his royal patient of a long-standing stomach trouble." The Indian physician also translated the Susruta-Saˆmhita into Arabic under the title of Kitab-Shawasoon al-Hind of 'Susrud'. The famous Persian physician al-Razi (860-925 AD) quotes 'sasrad' as an authority on surgery. But in India the school of Susruta did not flourish as much as the Caraka school of therapeutic medicine. Even today the šyurvedic medicine is mainly therapeutic, and surgery is regarded the domain of modern specialists.