Sushrut compiled the knowledge and teachings of his guru Divodas Dhanvantari, King of Kashi, in the Sushrut Samhita. It was common for surgeons then to be associated with kings, as has been cited in the Rg Veda, Mahabharat, Sushrut Samhita and Kautilya’s Arthashastra. Sushrut and his descendants are said to pre–date Panini, the great Sanskrit grammarian. Patanjali in his Mahabhashya and Katyayan in the Varttika also mention Sushrut. However scholars ascribe Sushrut’s true period to 1000 BCE (Sharma 1999: 87).
During his era, surgery formed a major role in general medical training. It was known as Shalya–tantra – Shalya means broken arrow or sharp part of a weapon, and tantra means manoeuvre. Since warfare was common then, the injuries sustained led to the development of surgery as a refined scientific skill.
Apart from being a treatise primarily on surgery, the Sushrut Samhita encompasses the other seven Ayurvedic faculties. Sushrut also details surgical procedures in other specialised branches which warrant surgery, such as obstetrics, orthopaedics and ophthalmology. To consider an example of the latter, he describes a method of removing cataract, known today as ‘couching’. This was routinely practised by Ayurvedic surgeons in India over the ages until the late half of the twentieth century. For successful surgery Sushrut induced anaesthesia using intoxicants such as wine and henbane (Cannabis indica). This led A.O. Whipple in his Story of Wound Healing (1965), to comment, must be accepted as a pioneer in some form of anaesthesia.” The depth of his expositions in such a variety of faculties reflects his brilliance and versatility. He asserted that unless the surgeon possessed knowledge of the related branches, he does not attain proficiency in his own field.
Like his guru Dhanvantari, Sushrut too, considered the knowledge of anatomy obligatory for a surgeon to be skilled in his art. This necessitated dissecting cadavers. Alongwith anatomy, Sushrut gives details of human embryology in Sharirsthan, which are mind–boggling. This is all the more astounding when we bear in mind that such detailed observation is today only possible using microscopy, ultrasonography and X–rays. To cite just one example, he mentions that the foetus develops seven layers of skin, naming each layer and the specific diseases which may affect that layer in adult life! (Sharirsthan IV–3). He was also aware of diseases by genetic inheritance. He mentions many congenital defects acquired from parents and those resulting from indulgences of the mother during pregnancy. Therefore he advises her to avoid exertion for the perfect development of the foetus. For instance, she should avoid physical exertion, daytime sleep, keeping awake late into the night, extreme fasting, fear, purgatives, travelling on a vehicle, phlebotomy and delaying the calls of nature (Sharirsthan III.11).
Sushrut’s era, as all down the ages, involved warfare. This meant injury from weapons such as arrows often embedding as splinters – shalya. He has categorised two types of symptoms for splinters – general and specific – from which a diagnosis can be made, of the type of splinter and its exact depth. He further details the different symptoms for different splinters of bone, wood, metal embedded in skin, muscle, bones, joints, ducts, pipes or tubes. He then prescribes fifteen different procedures for removing loose splinters. Two notable methods for problematic splinters though seemingly extreme, are highly effective and innovative. If a splinter is lodged in a bone and fails to budge, its shaft should be bent and tied with bowstrings. The strings should be tied to the bit of the bridle of a tame horse. While holding the patient down, the horse should be slapped or hit with a stick so that it jerks its head. In doing so, the splinter is forced out! If that fails, one could pull down a strong branch of a tree and tie the splinter to it. One then lets go of the strained branch, which will draw out the splinter!
Besides splinter injuries, Sushrut also deals with trauma. He describes six varieties of accidental injuries encompassing almost all parts of the body:
Chinna: Complete severance of a part or whole of a limb
Bhinna: Deep injury to some hollow region by a long piercing object
Viddha prana: Puncturing a structure without a hollow
Kshata: Uneven injuries with signs of both chinna and bhinna, i.e.
Pichchita: Crushed injury due to a fall or blow
Ghrsta: Superficial abrasion of the skin
Besides trauma involving general surgery, Sushrut gives an in–depth account and treatment of twelve varieties of fractures and six types of dislocations, which would confound orthopaedic surgeons today. He mentions principles of traction, manipulation, apposition and stabilisation, as well as post–operative physiotherapy!
Being a genius and a perfectionist in all aspects of surgery he even attached great importance to a seemingly insignificant factor such as scars after healing. He implored surgeons to achieve perfect healing, characterised by the absence of any elevation or induration, swelling or mass, and the return of normal colouring. He went as far as prescribing ointments to achieve this, managing to change healed wounds from black to white and vice versa!
He also prescribed measures to induce growth of lost hair and to remove unwanted hair. Such minute detailing reflects his deep insight, rendering him the first surgeon in world history to practice a holistic approach in treating surgical patients. According to Sankaran and Deshpande, “No single surgeon in the history of science has to his credit such masterly contributions in terms of basic classification, thoroughness of the management of disease and perfect understanding of the ideals to be achieved” (1976:69). To Sushrut health was not only a state of physical well–being, but also mental, brought about and preserved by the maintenance of balanced humours, good nutrition, proper elimination of wastes and a pleasant, contented state of the body and mind.
Finally, from the patient to the surgeon. He gave a definition of an ideal surgeon embodying all possible requisites, which has yet to be improved upon even today. “He is a good surgeon,” he declares, “who possesses courage and presence of mind, a hand free from perspiration, tremorless 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.”
Sushrut’s excellence in surgery and original insights in all branches of medicine render him the most versatile genius in the history of medical science. His contributions have withstood the test of over three thousand years. In the absence of sophisticated instruments available to us today, his profound observations then may be attributed to two factors: grace of a stalwart guru, Dhanvantari, and divine revelation through personal sadhana – meditation. These observations of an ancient rishi, today continue to intrigue researchers at the Wellcome Institute of the History of Medicine in London and other similar institutions in Europe, USA and India.
Reconstructive Surgery in India
In 1792 Tippu Sultan’s soldiers captured a Maratha cart–driver named Cowasjee (Kawasji) in the British army and cut of his nose and an arm. A year later, a kumbhar (potter) vaidya in Puna reconstructed Kawasji’s nose. Two British surgeons in the Bombay Presidency, Thomas Cruso and James Findlay witnessed this skilful procedure and noted the details. In October 1794, this account was published in The Gentleman’s Magazine of London, describing it as an operation ‘not uncommon in India and has been practiced for time immemorial’! This procedure, similar to that cited in the Sushrut Samhita, ultimately changed the course of plastic surgery in Europe and the world. It was different from Sushrut’s, in that Kawasji’s graft was taken from his forehead. Sushrut grafted skin from the cheek. To aid healing, he prescribed the use of three herbs and cotton wool soaked with sesame seed oil in dressing the graft. After the graft healed, he advocated cutting off the tissue joined to the cheek (Sutrasthan 16/18).
Regarding cosmetic surgery, Sushrut could also reconstruct ear lobes and enumerates fifteen ways in which to repair them. Guido Majno in The Healing Hand: Man and Wound in the Ancient World (1975), notes that, “Through the habit of stretching their earlobes, the Indians became masters in a branch of surgery that Europe ignored for another two thousand years.” Sushrut meticulously details the pre–and post–operative procedures. After stitching, for example, he prescribes dressing the lobe by applying honey and ghee, then covering with cotton and gauze and finally binding with a thread, neither too tightly nor too loosely. Torn lips were also treated in a similar manner (Sutrasthan 16/2–7, 18, 19).