Susruta and our Medical Heritage
We, in this country, regard Susruta as the “Father of Plastic Surgery.” Who was Susruta? When and where did he live and work? These questions can only be imperfectly answered like similar questions. In respect of the lives of our ancient worthies. The Susruta Samhita would have us believe that once upon a time a number of sages approached Dhanwantari alias Divodasa, King of Kasi, who received Ayurveda from divine sources – Brahma via Prajapati, the Aswins and Indra. Dhanwantari imparts medical knowledge to these sages, and one of them called Susruta codified his oral instructions. There is no sure ground proving the historicity of Susruta, which literally means “that which is well heard” or “one who has thoroughly learned by hearing.” It is more likely the anonymously edited manual of a school which had selected Susruta as patron. It is only safe to assert that Susruta was of the race of Viswamitra as represented in the Mahabharata- Anushasan Parva, chapter IV. Divodasa, the preceptor of Susruta, is represented as an incarnation or descendant of Dhanwantari, the first propounder of surgical science. The name of the original work was Shalya Tantra (Skt Sala = surgical instrument). Beyond this meagre genealogy we possess no trustworthy information regarding the life and personality of Susruta.
We have no means of ascertaining what the Samhita was like as originally written by Susruta, the present form is a recession or rather a recession of recessions made by Nagarjuna who opinions identify as the founder of the Madhyamika or Northern School of Buddhist philosophy around the second century B.C. A few quotations from the Vridha (Old) Susruta are all that are preserved of the original Samhita, but their genuineness is of a problematic character, and we are not sure whether they are the production of lesser lights, or of ancient though less renowned commentators, attributed to the master to invest them with greater sanctity and authority. The most renowned commentary on Susruta Samhita is that of Dalhana (12th century A.D.) called Nabanda Samagraha. Other notable commentators were Gayadasa (10th century A.D.) and Candrata (12th century A.D.).
At the time of the Mahabharata which nearly approaches the age of Susruta the number of sects among the followers of the healing art numbered five, which were named Rogaharas (physicians), Shaylyaharas (surgeons), Vishaharas (poision curers), Krityaharas (demon doctors) and Bhisagatharvans (magic doctors). Susruta’s Compendium is also mentioned in the Bower Manuscript that was found in 1890 in a ruined Buddhist stupa in Kashgar, on the western outskirts of the Gobi Desert, and translated by A.F.R.Hoernle in 1909 at Calcutta. The medical texts were written in the Pali script of the Gupta period according to palaeographic criterion which gives the beginning of the fifth century A.D. as the latest possible date for the text.
The upshot of these arguments is that in Susruta’s text we have a work the kernel of which probably started some centuries B.C. in the form of a text mainly on surgery, but which was then heavily revised and added to in the centuries before 500 A.D. This is the form in which we have received the work in the oldest surviving manuscript today.
Susruta gives us a historical window into a school of professionalized surgical practice almost two millennia ago, and which was in its day, almost certainly the most advanced school of surgery in the world. Many details in the description could only have been written by a practising surgeon and it is certain that elaborate surgical techniques were a reality in Susruta’s circle.
The first translation of Susruta Samhita were ordered by the Caliph Mansur (A.D.753 -774) who had embassies come from his province of Sind to Baghdad along with Hindu scholars bringing books. The Caliph Harun (A.D.786-808) appointed Hindu physicians to Baghdad hospitals and ordered further translations into Arabic of books on medicine, pharmacology, toxicology, astronomy and other subjects. Alberuni who was a member of the court of Mahmud of Ghazni (A.D.997-1030) mentions the current translation of Caraka although complaining of its incorrectness. The centres of Indian learning in his times were Banaras and Kashmir, both inaccessible to the invading armies of Mahmud. The first European translation of Susruta Samhita was published by Hessler in Latin in the early 19th century. The first complete English translation was done by Kaviraj Kunja Lal Bhishagratna in three volumes in 1907 at Calcutta. New sources have been discovered in Tibetan versions, Tamil sources and Mongol versions of Tibetan translations. Indian medicine has played in Asia, the same role as Greek medicine in the West, for it spread to Indo-China, Tibet, Central Asia, and as far as Japan.
The contributions regarding Plastic Surgery in Susruta Samhita are the following:
1. Rhinoplasty by cheek flap.
2. Classification of mutilated ear lobe defects.
3. 15 techniques for repair of torn ear lobes.
4. Cheek flap for reconstruction of absent ear lobe.
5. Repair of cleft lip.
6. Piercing children’s ear lobe with a needle or awl.
7. Suture materials of bark, tendon, hair and silk.
8. Needles of bronze or bone, circular, two finger-breadths wide and straight, triangular bodied, three finger – breadths wide.
9. Classification of burns into four degrees – singeing, blister, superficial and deep.
10. Different methods of dressings with various medicaments.
11. Wine to dull the pain of surgical incisions.
12. 101 types of blunt instruments (yantras) and 20 varieties of sharp instruments. According to Susruta the hand is the most important yantra, for without it no operation could be done.
13. Surgical demonstration of techniques of making incisions, probing, extraction of foreign bodies, cauterization, tooth extraction, scarification, excisions, trocars for draining abscess, saws for amputations on various natural fruits, dead wood, and clay models.
14. A system of anatomical dissection of cadavers.
15. Operations for lithotomy, intestinal sutures, couching for cataract, caesarian section to save a live baby if the mother dies in labour and other surgical procedures are mentioned. Ligaturing of bleeding vessels was not known, the bleeding being checked by pressure, cautery or boiling oil.
16. A code of ethics for teachers as well as students.
There is little historical evidence to show that these practices persisted beyond the time of the composition of Susruta’s compendium. A few references to surgery found in Sanskrit literature between the 4th to the 8th century A.D. were collected by P.V. Sharma (1972), but the stereotypical nature of most of these references and the paucity of real detail, suggests that the practice of surgery was rare in this period. There is some evidence, however, that although surgery ceased to be part of the professional practice of the traditional physicians of the vaidya caste, it migrated to surgeons of the “barber surgeon” type. As such, it was no longer supported by the underpinning of Sanskrit literary tradition, so it became harder to find historical data about the practice. D.C. Sircar (1987) discusses some epigraphical evidence for the heritage and migrations of the “Ambastha” caste who appears to have functioned as barber surgeons in South India and later migrated to Bengal.
By the 17th century, foreign visitors began to remark on how surgery was virtually non- existent in India. The French traveller, Travernier for example, reported in 1684 that once when the King of Golconda had a headache and his physician prescribed that blood should be let in four places under his tongue, nobody could be found to do it Col. W.S. Sleeman (1893) in his “Rambles and Recollections of an Indian Officer” observed on the same lack of surgeons.
The famous Indian Rhinoplasty method is often cited as evidence that Susruta’s surgery was widely known in India even up to comparatively modern times. The operation took place in March 1793 in Poona. A maratha named Cowasjee who had been a bullock-cart driver with the East India Company Army in the Third Mysore War of 1792 was captured by the forces of Tipu Sultan and had his nose and one hand cut off. (A residual puzzle with this account is that ‘Cowasjee’ in a Parsi name, not a Maratha one). After an year without a nose, he and four of his colleagues, who had suffered the same fate, submitted themselves to treatment by a man who had a reputation for nose repairs. Unfortunately, we know little of this man, except that he was said in one account to be of the brick-maker’s caste and by Cowasjee’s commanding officer Lt. Col. Ward as an ‘artist’ whose residence was 400 miles distant from Poona. Thomas Cruso and James Findlay, senior British surgeons in the Bombay Presidency, witnessed this operation.
They appear to have prepared a description of what they saw and diagrams of the procedure. The details and an engraving from the painting were published at third hand by Barak Longmates a journalist in 1794 in ‘The Gentleman’s Magazine and Historical Chronicle (66.4 pp.883, 891 and 892). The key innovation was the transplantation of skin from the site immediately adjacent to the defect, while keeping the graft tissue alive and supplied by blood through a connecting skin bridge. Subsequently, through the publication by Carpue (1816) describing his successful use of the technique this method of nose repair gained popularity amongst British and European surgeons. Personal inquiries by Carpue from Cowasjee’s commanding officer Lt. Col. Ward described the understanding in Poona, at the time of the operation, that this artist – surgeon was the only one of his kind in India and that the art was heriditary in the family.
The technique used by Cowasjee’s surgeon was similar, but not identical, to that described in Susruta’s Compendium. Susruta’s version has the skin flap being taken from the cheek; Cowasjee’s was taken from the forehead. The Sanskrit text of Susruta’s description is brief and does not appear to be detailed enough to be followed without an oral commentary and practical demonstration, although an experienced surgeon might be able to discern the technique even so. It is hard to see how such techniques could have persisted purely textually. Maybe, the Poona operation is indeed an extraordinary survival of a technique from Susruta’s time, but in that case it seems to have been transmitted through channels outside the learned practice of traditional Indian physicians.
Ayurvedic literature is preserved almost exclusively in the Sanskrit language, and originally in the form of manuscripts written on birch bark , palm leaves or paper. India has, over the millennia, developed about a dozen different alphabets. The scribe who copied out the manuscripts would use the script that was local to the place of work. So it is quite normal to find Sanskrit medical manuscripts from Kerala in the Malayalam script, while a manuscript of the very same text copied in Bengal would be in the Bengali script. Both manuscripts would still be in the Sanskrit language and would be virtually indistinguishable if read aloud.
No systematic effort has been made to collect together all the known manuscripts of Susruta Samhita, let alone compare them all, try to classify them, to tease apart the historical strata in the texts, weed out scribal errors, and adjust the readings of the texts accordingly. The printed editions are vulgate texts, that is so say, they are books printed on the basis of small number of manuscripts from a local region, normally Bombay or Calcutta. And the decisions about what to print when the manuscripts disagree was made on the basis of general common sense but without the support which historical philology and textual criticism can offer. Criterion for determining what is intrinsic and what is extrinsic to rationalist medicine in the Susruta Samhita is based on the observation that medical science is concerned with specifically four factors: the doctor, the substance used (drug or diet), the nursing attendant and the patient. The qualifications essential to each are also specified. The discussion concerned with these are intrinsic to medical science. By contrast, any topic unconnected with these – howsoever may be their importance in philosophy, religion and traditional morality – are extrinsic to medicine.
Today, Ayurveda is one of the six medical systems that are officially recognized by the Indian Government, the others being allopathy (modern medicine), homeopathy, naturopathy, unani, siddha and yoga therapy. The practitioners of the six systems must compete for patients with each other and with a profusion of practitioners of other medical skills, including itenerant tonic sellers, pharmaceutical representatives, village curers, bone setters, midwives, exorcists, sorcerers, psychics, divines, priests, astrologers, grandmothers, wandering religious mendicants and experts in such maladies as snakebite, hepatitis, infertility and ‘sexual weakness’. Indian people talk knowingly or not in the Ayurvedic idiom. Even the illiterate peasant of a remote village knows that yoghurt causes phlegm to accumulate in the chest, and everyone uses simple herbs like vetiver (cus cus) which remove ‘heat’ from the body and makes life during the hot summers a little more bearable. Ayurvedic thought is part of the conceptual universe of every Indian and has been a part of its collective consciousness since very early times.
“The difficulty lies not in the new ideas, but in escaping the old ones, which ramify into every corner of our minds.”