Surgery seems, and is most likely known, to be an invention of the modern age to most. Given its common prevalence in the present day-n-age, many assume that ‘plastic’ surgery is a modern luxury even though the desire to attain physical beauty and a general curiosity regarding the human body have been a human endeavour since time immemorial. From cosmetic to reconstructive purposes, surgery has been, and is, an important part of the medical field.
In order to rectify this oversight, we’d have to ask
the question as to where did it all start? It turns out that surgery has been
around longer than most people realize and that the roots of cosmetic and
reconstructive surgery procedures go back more than a couple of millennia. The
earliest instances of surgery as we know today, date back to the 6th
Century BCE with detailed records that can be found in the Sushruta Samhita, an
important Indian medical text.
Sushruta has been widely regarded as the “Father of Surgery” owing to his seminal and numerous contributions to the field. He was an ancient surgeon who lived, taught and practiced his craft on the banks of the Ganges in the area that corresponds to the present-day city of Varanasi in Northern part of India. He was perhaps the first one to lead directive into plastic surgery, records of which have been found well-written on papyrus leaf. This compendium called Sushruta Samhita in its current, redacted form comprises of 184 chapters and documents the aetiology of 1,120 illnesses, 700 medicinal plants, 64 preparations from mineral sources and 57 preparations from animal sources. In addition to that, over 300 surgical procedures and 120 surgical instruments have been included. Sushruta had directed that a surgeon be equipped with 20 sharp and 101 blunt instruments largely made of steel for specific purposes. These instruments
Owing to these developments at the time, it was in surgery that the ancient Hindu medicine reached its zenith. Among the varied operations performed by the surgeons, the important ones included excision of tumours, incision and draining of abscesses, punctures to release fluid in the abdomen, extraction of foreign bodies, repair of anal fistulas, splinting of fractures, amputations, caesarean sections, and stitching of wounds. The most outstanding of these were lateral lithotomy that was used frequently to remove bladder stones (vesical calculus) as it was fairly common back then, and rhinoplasty called as the Nasikasandhana in the texts. It is the reconstruction of the nose that really laid the foundation for the field of surgery.
It is intriguing as to why did a surprisingly large number of noses in India needed to be reconstructed but the answer isn’t quite that elusive. Noses were taken to be symbols of pride so obviously they proved to be quite tempting targets during warfare. Similarly, the amputation of the nose was considered as a proper and just punishment for legal transgressions and other offenses including adultery. The description of the operation done by Sushruta is amazingly meticulous and comprehensive. The repair was carried out by cutting a piece of tissue of the required size and shape from the patient’s cheek or forehead and applying it to the stump of the nose. This first written record of a forehead flap rhinoplasty is a definite pathbreaking feat as it’s the same technique that’s still used today implying that the derivation has been indirectly taken from the ancient source.
Skin grafts are used by modern day surgeons to restore areas that have lost protective layers of tissue due to trauma, infection, burns, as well as to repair areas where surgical intervention has resulted in loss of skin, as happens with melanoma removal. Some forms of grafts even include blood vessels and muscle like in reconstructive breast surgery. In all this the amazing aspect remains that all these techniques that are relevant today are all explained in Sushruta’s treatise.
How it came to be
Due to religious beliefs and restrictions, Hindus were prohibited from cutting cadavers. Because of this the knowledge of anatomy was limited. Therein came Sushruta who worked his way around these by devising ingenious and experimental methods. His treatise recommends that a dead body be placed in a basket and sunk in a river for seven days following which the parts could easily be separated without the need of any cutting. These crude methods resulted in the emphasis in Hindu anatomy being given first to the bones and then to the muscles, ligaments, and finally the joints. The knowledge on nerves, blood vessels, and internal organs was far from perfect. As per the beliefs, the body was taken to be made up of three elementary substances that represented microcosmic representatives of the three divine universal forces. They called them spirit (air), phlegm, and bile. General health was attributed to the normal balance of these three substances in the body since the seven primary constituents namely blood, flesh, fat, bone, marrow, chyle, and semen were produced by their actions.
The physicians employed all the five sense for diagnosis. Hearing was used to distinguish the nature of the breathing, voice alteration, and the grinding sound produced by the rubbing together of broken ends of bones. Through their good clinical sense, their discourses contain acute references to symptoms that had grave results. Despite their efforts, the magical and superstitious beliefs still persisted until late in the classical period thereby affecting the prognosis by coincidental factor as the cleanliness of the messenger sent to fetch the physician, the nature of his conveyance, or the types of persons the physician met on the way to the patient. Dietetic treatment was deemed important and preceded any medicinal remedy. Fats were used both internally and externally. The “five procedures” of the administration of emetics, purgatives, water enemas, oil enemas, and sneezing powders were the most essential methods of active treatment. Some other frequently administered methods were inhalations, cupping, leeching, and bleeding.
Keeping all these in mind Sushruta, along with his selected disciples and assistants conducted and successfully ascertained surgeries that ranged from simple to complex ones. He dedicated at least one student to observe his procedures in a magnified manner and take notes of each step for future references. His popularity soon soared and patients and even medical practitioners from overseas flocked about round the clock and it’s said that he never turned anyone away. He made his disciples practice ‘incision’ and ‘excision’ on vegetables and leather bags filled with mud of different densities, ‘probing’ on moth eaten or bamboo, and ‘puncturing’ on the veins of dead animals and lotus stalks to get a feel for the human body since refrainment was to be exercised. He was also, in a way, the pioneer of anaesthesia and guided about the proper use of wine with incense of cannabis for the purpose. Apart from the usage of narcotic during operations, the bleeding was stopped by hot oils and tar.
Sushruta ascertained that a good doctor should possess medical knowledge in both its theoretical and practical forms. He wanted to expound and share all that he had learned about medicine and healing from Divodasa who was the King of Kashi (present day Varanasi). The king was believed to be the incarnation of Dhanvantari the God of Ayurvedic medicine.
Other significant and notable inclusions
Sushruta Samhita can easily be referred to as the encyclopaedia of medical learning for doctors with special importance on the Shalya tantra, a vital branch of Ayurveda the literal meaning of which is the removal of an irritating factor from the body, and Shalakya tantra that deals with prevention and treatment of diseases in and around the head.
The treatise is divided into two distinct parts that expand the scope further by describing the sciences and practices of paediatrics, geriatrics, diseases of the ear, nose, throat and eye, toxicology, aphrodisiacs, and psychiatry.
The first of the two, Purva-tantra is dedicated to
Ayurveda’s four branches. It has in all about 120 chapters proportioned into
five sections that are:
1. Sutra-sthana: The introduction lays the foundation for the whole compendium by describing the basic principles.
2. Nidana-sthana: Dedicated to aetiology which is the signs and symptoms of important surgical diseases and those ailments which have a bearing on surgery
3. Sarira-sthana: Covers the rudiments of embryology and the anatomy of the human body along with instructions for venesection, which is the positioning of the patient for each vein, and protection of vital structures. The essentials of obstetrics are also included here.
4. Kalpa-sthana: Deals mainly with the nature of poisons and their management
5. Chikitsa-sthana: Describes the principles of management of surgical conditions including obstetrical emergencies and chapters on geriatrics and aphrodisiacs The second part, Uttara-tantra has been called Aupadravika since many of the complications of surgical procedures, as well as, fever, dysentery, cough, hiccough, krimi-roga which is the symptoms and treatment of worms, pandu (anaemia), kamala (jaundice), etc., are described here. It holds four specialities:
1. Shalakya: Describes various diseases of the eye, ear, nose, and head
2. Kayachikitsa: It’s about internal medicine and is the first branch of Ayurveda where ‘kaya’ means body and ‘chikitsa’ stands for treatment
3. Kaumarabhfefefrtya: One of the most important branch amongst Ashtanga Ayurveda as it deals with the prevention and cure of childhood diseases
4. Bhutavidya: Literally means psychiatry and the science of spirits and deals with the diseases of mind or psychic conditions which were believed to be even caused by ‘supernatural’ forces. Some believe that ‘bhuta’ could even represent microscopic organisms such as virus, bacteria that aren’t visible to the naked eye.
The remarkable aspect remains that there’s still so much to unearth in the text that the mention of surgical techniques of making incisions, probing, extraction of foreign bodies, alkali and thermal cauterization, tooth extraction, excisions, and trocars for draining abscess, hydrocele and ascitic fluid, the removal of the prostate gland, urethral stricture dilatation, vesicolithotomy, hernia surgery, caesarean section, management of haemorrhoids, fistulae, laparotomy and management of intestinal obstruction, perforated intestines, and accidental perforation of the abdomen with protrusion of omentum, are like scratching the surface.
The inclusion of the principles of fracture management, viz., traction, manipulation, appositions and stabilization including some measures of rehabilitation and fitting of prosthetics is yet another astonishing component. It enumerates six types of dislocations, twelve varieties of fractures, and classification of the bones and their reaction to the injuries.
It also gives a classification of eye diseases including cataract surgery by couching, or displacing the lens to improve vision.
It is no wonder then that Sushruta’s era is regarded as ‘The Golden Age of Surgery’ in Ancient India as he took surgery to an astonishing height. The later translations into Arabic, Latin, and English languages bear further testimony to the worldwide popularity and acknowledgment of his great contribution to the field as it continues to hold an important place in the medical arena.