Susruta: The Great Surgeon of Yore
by D.P. Agrawal
Ayurveda, the ancient Indian medicine system is better recognised now by the West. It is less known that great strides were made in the field of surgery too. Rhinoplasty, inoculation against small pox etc were practiced in India even as late as the 18th Century AD, as shown by Dharampal. Indian surgery has great potentialities for research. The Indian technique of rhinoplasty has earned many laurels outside the country. Similarly, plastic surgery as a whole, management of injuries, and some simple measures as substitutes of surgical manipulations have of late been brought to light. Susruta was a great surgeon of ancient India, though there is considerable controversy about his age.
Surgical science was called Salya-tantra (Salya – broken parts of an arrow and such other sharp weapons; tantra – manoeuvre). The broken parts of the arrows or similar pointed weapons of the enemy were regarded as the commonest and most dangerous of foreign objects causing wounds and requiring surgical treatment. Thus a primitive sort of surgery was as old as warfare itself.
Susruta is stated to be the son of Visvamitra in the the Susrutasamhita. The The exact identity of this Visvamitra is not known clearly. Sustruta was sent to study Ayurveda with special emphasis on Salya (surgery) under Divodasa Kasi Raja Dhanvantari of the Upanishadic age. Since the text contains a reference to Krishna the identity and chronology of his father Visvamitra becomes confused.
Date of Susruta
Though there is general agreement about the great antiquity of Susruta, there is considerable controversy about his exact age.
Lietard and Max Neuburger were of the opinion that Susrutra must have lived as late as the 1st century A.D. to 10th century A.D. The discovery of the Bower manuscript which contains reference to Susruta and which has been ascribed to the 4th century A.D. led Macdonell to place Susruta not later than the 4th century A.D. But Hessler and Mukhopadhyaya believed that Susruta should have lived at about 1000 B.C.
Nagarjuna’s Upayahrdaya refers to Susruta and this takes him definitely to a period before Nagarujna who is believed to have lived about 2000 years ago. Further, Susruta has been mentioned both in Mahabhasya of Patanjali and the Varttika of Katyayana. It seems that the descendants of Susruta were earlier than Panini, the great grammarian. Although the grammatical works do not mention Susruta to be the promulgator of Salyatantra, all the grammarians quote him as the famous teacher and originator of a specialised branch of learning, and the followers were known after him as Sausrutas.
No other teacher in the name of Susruta is known except the medical writer who was the propagator of Salyantantra. Hence, Susruta is believed to be older than Panini, though there are others who push his antiquity back to 3000BC, which does not seem tenable. Hoernle places Susruta at about 600 B.C. as Susruta counts only 300 bones in the body and on this ground, Hoernle believes him to be posterior to Atreya and Yajnavalkya and thus takes him to 600 B.C.
Susruta and his fellow-students started their education under Divodasa Dhanvantari. Divodasa explains to them briefly the nature of the purusa (person) who is afflicted with disease and who is to be treated: the nature of disease which causes pain and its eradication; the types of food, the dravyas and the time-factor. He also asks his students to consult as many other disciplines as necessary in order to attain sound knowledge in one’s own subject. Amongst the illustrious students of Divodasa were Aupadhanava, Aurabhra, Susruta and Paushkalavata who wrote treatises on Salyatantra (surgery) which became the sources of the later works on this subject.
Susruta is the author of the Susrutasamhita, the work known after his name, and one of the most brilliant gems in Indian medical literature, and thus he is recognised as the father of Indian surgery. There are references to accidental loss of leg of Vispala and she was immediately given an iron leg-prosthesis to walk with. The origin of the surgery can be traced back to the earliest times, probably back to the Indus Civilisation as some of the artefacts seem to suggest. The Rgveda mentions many a surgical feat of the celestial twin medical experts, the Asvins. Amongst the eight divisions of medical knowledge (Ayurveda), surgery was considered the first and the most important branch.
It seems that the ancient thoughts on medicine and surgery were confined to texts called Kalpas, small monographs. Early Indian medical literature was full of such monographs or handbooks. Agnivesa gave shape to such knowledge by gathering, pruning, enlarging and emphasising important aspects into text-books of medicine as early as 1200 B.C. The ancient Indian medical practitioners were divided into two classes: the Salya-cikitsakas (surgeons) and the Kaya-cikitsakas (physicians). Surgery had not yet been incorporated into the encyclopaedic tradition as represented by the Agnivesatantra. It was through the efforts of Susruta that surgery achieved a leading position in general medical training.
The composition of Susruta, known as the Susrutasamhita after his name, is the transalation of what he learnt at the feet of his preceptor Divodasa Dhanvantari. We have seen that along with Susruta, Aupadhenava, Vaitarana and others too had their instruction from Divodasa and each in his turn prepared a treatise on Salyatantra. The present Samhita itself reveals that there existed many such works on surgery and the one belonging to Aupadhenava, Aurabhra, Pauskalavata and Susruta were the source books for the rest of the treatises. Amongst these compositions, only the Susrutasamhita is extant, and apart from the redactions by Nagarjuna, Candrata and the commentators, it has remained the only treatise for two of the eight branches of Ayurveda, namely Salya and Salakya.
After attaining such great heights in the remote past, surgery was subsequently neglected; abandonment of dead body dissection and relegation of the manual work to inferior artisans gradually deprived those who studied the work of Susruta of practical knowledge. Thus while internal medicine advanced with time, surgery declined and was finally reduced to mere theory, except for some traditional families practicing it.
The Susrutasamhita is in two parts, the Purva-tantra in five sections and the Uttara-tantra. Those two parts together encompass, apart from Salya and Salakya, the other specialities also like medicine, pediatrics, geriatrics, diseases of the ear, nose, throat and eye, toxicology, aphrodisiacs and psychiatry. Thus the whole Samhita, devoted as it is to the science of surgery, does not fail to include the salient portions of other disciplines too. In fact, Susruta emphasises in his text that unless one possesses enough knowledge of relevant sister branches of learning, one cannot attain proficiency in one’s own subject of study.
The Samhita is thus an encyclopaedia of medical learning with special emphasis on Salya and Salakya. Sutra-sthana, Nidana-sthana, Sarira-sthana, Kalpa-sthana and Cikitsa-sthana are the five books of the Purvatantra containing one hundred and twenty chapters. Incidentally, the Agnivesatantra known better as the Caraksamhita and the Astangahrdaya of Vagbhata also contain one hundred and twenty chapters in all. The Nidana-sthana gives the student the knowledge of aetiology, signs and symptoms of important surgical diseases and those ailments, which have a bearing on surgery. The rudiments of embryology and anatomy of human body along with instructions for venesection (cutting of veins), the positioning of the patient for each vein, and protection of vital structures (marma) are dealt with in the Sarira-sthana. This also includes the essentials of obstetrics.
Principles of management of surgical conditions including obstetrical emergencies are contained in the Cikitsa-sthana, which also includes a few chapters on geriatrics and aphrodisiacs. The Kalpa-sthana is mainly Visa-tantra, dealing with the nature of poisons and their management. Thus the Purva-tantra embraces four branches of Ayurveda. The Uttara-tantra, contains the remaining four specialities, namely, Salakya, Kaumarabhrtya, Kayacikitsa and Bhutavidya. The entire Uttara-tantra has been called Aupadravika since many of the complications of surgical procedures like fever, dysentery, cough, hiccough, krmi-roga, pandu, kamala, etc., are briefly described here. The Salakya-tantra portion of the Uttara-tantra contains various diseases of the eye, the ear, the nose and the head. Thus the whole Samhita is one comprehensive treatise on the entire medical discipline.
It is generally agreed that this Samhita in the present shape is the outcome of the efforts of not one person but of several. Susruta, the son of Visvamitra and student of Divodasa Dhanvantari, the king of Kasi, should have been the first author of this Samhita as a whole or of the portion short of Uttara-tantra. A certain Vrddha Susruta or Susruta the elder is also mentioned by some commentators of this Samhita. Dalhana says that the Pratisamskarta or redactor of this Susruta-samhita was Nagarjuna. Who this Nagarujuna was is not clear. There had been many Nagarjunas in the past.
On the whole, the entire Samhita is a complete work on medicine with special attention to Salya and Salakya tantras. The succinct and sombre style and the overall superiority of the Susrutasamhita led to the extinction of other treatises which preceded this compilation or were contemporary. As a text-book, it is unrivalled in respect of composite teaching of the subject of surgery with reference to all allied branches of medical learning required by a surgeon. It is a forerunner of Vagbhata’s Astanga-sangraha.
Susruta ordains that anyone who wants to attain surgical skill should study anatomy by practical observation of the various structures composing the body. The study of anatomy is dealt with in the Sarirasthana of the Susrutasamhita. He proposed first to deal with embryology and then anatomy of human body which is an extension of the embryo. He further deals with obstetrics and embryology together. After this, the Samhita describes the sequential development of the structures of the foetus. For this study of anatomy, Susruta advocates dissection of dead body.
Perhaps we could evaluate the status of surgery during any period by the type of instruments in vogue during that period. Susruta gives a list of blunt and sharp instruments and adds that a surgeon, by his own experience and intelligence, may invent and add new instruments to facilitate the surgical procedures. He points out that the hand is the most important and the best instrument but for which the operation of other instruments ceases. The blunt instruments are meant for removal of foreign bodies, for sucking the fluids, for facilitating the various surgical procedures and for visualising the lesions. The double-armed axile instruments, which have two moving limbs to hold and pull any object are called svastika-yantras and they resemble the various types of forceps.
Susruta’s classification and description became the basis for the development of instruments. In fact he can be said to have been the first person to introduce the diagnostic instruments and their principles, which were modified later with the introduction of optical system in their construction. Fourteen types of bandaging capable of covering almost all the regions of the body are described for the practice of the student on dummies. Some important procedures, which preceded actual surgery, as cauterisation by Ksaras (alkaline substances) or Agni and application of leeches were being practised extensively. Thermal cauterisation for therapeutic purposes has been advocated by heating various substances and applying them at the desired sites. This type of practice seems to be quite old and is used in the Himalayan Medicine system also and is known as Tau-Dam.
Susruta has covered the accidental burns in its four degrees, the effect of heat-stroke, sun-stroke and frost-bite due to excessive cold and also the effect of lightning which he calls vidyut-dagdha. This classification underlines his view that all thermogenic trauma, whether due to extreme cold or heat, either wet or dry, chemical or inert fluid, produces damage almost similar and hence has to be managed as one entity. The great value of Susruta’s classification could be realised from the fact that this concept gained validity in modern surgery only recently after 1950 and is now uniformly accepted in the classification and management of these injuries.
Susruta has pointed out that haemorrhage can be arrested by apposition of the cut edges with stitches, application of styptic decoctions, by cauterisation with chemicals or heat. That the progress of surgery and its development is closely associated with the great wars of the past is well known. The vrana or injury, says Susruta, involves breakdown of body-components and may have one or more of the following seats for occurrence, viz., skin, flesh, blood-vessels, sinews, bones, joints, internal organs of chest and abdomen and vital structures. Classically vrana, the wound, is the ultimate explosion of the underlying pathological structure. It is, in Susruta’s words, the sixth stage of a continuous process, which starts with sotha (inflammation).
Susruta says that in the first stage, the ulcer is unclean and hence called a dusta-vrana. By proper management it becomes a clean wound, a suddha-vrana. Then there is an attempt at healing and is called ruhyamana-vrana and when the ulcer is completely healed, it is a rudha-vrana. Susruta has advocated the use of wine as an anaesthesia. Although the use of henbane (Cannabis indica) and of Sammohini and Sanjivani are reported at a later period, Susruta was the pioneer of anaesthesia.
Susruta describes eight types of surgical procedures: Excision (chedana) is a procedure whereby a part or whole of the limb is cut off from the parent. Incision (bhedana) is made to achieve effective drainage or exposure of underlying structures to let the content out. Scraping (lekhana) or scooping is carried out to remove a growth or flesh of an ulcer, tartar of teeth, etc. the veins, hydrocele and ascitic fluid in the abdomen are drained by puncturing with special instrument (vyadhana). The sinuses and cavities with foreign bodies are probed (esana) for establishing their size, site, number, shape, position, situation, etc. Sravana (blood-letting) is to be carried out in skin diseases, vidradhis, localised swelling, etc. in case of accidental injuries and in intentional incisions, the lips of the wound are apposed and united by stitching (svana).
To obtain proficiency and acquiring skill and speed in these different types of surgical manipulations, Susruta had devised various experimental modules for trying each procedure. For example, incision and excision are to be practised on vegetables and leather bags filled with mud of different densities; scraping on hairy skin of animals; puncturing on the vein of dead animals and lotus stalks; probing on moth-eaten wood or bamboo; scarification on wooden planks smeared with beeswax, etc. On the subject of trauma, Susruta speaks of six varieties of accidental injuries encompassing almost all parts of the body.
Susruta also gives classification of the bones and their reaction to injuries. varieties of dislocation of joints (sandhimukta) and fractures of the shaft (kanda-bhagna) are given systematically. He classifies and gives the details of the six types of dislocations and twelve varieties of fractures. He gives the principles of fracture treatment, viz., traction, manipulation, appositions and stabilisation. Susruta has described the entire orthopaedic surgery, including some measures of rehabilitation, in his work.
As war was a major cause of injury, the name Salya-tantra for this branch of medical learning is derived from Salya, the arrow of the enemy, which in fights used to be lodged in the body of the soldiers. He emphasises that removal of foreign bodies is fraught with certain complications if the seat of the Salya be a marma.
Susruta also discusses certain surgical conditions of ano-rectal region, he has given all the methods of management of both haemorrhoids and fistulae. Different types of incision to remove the fistulous tract as langalaka, ardhalangalaka, sarvabhadra, candraadha (curved) and kharjurapatraka (serrated) are described for adoption according to the type of fistula.
Susruta was well aware of the urinary stones, their varieties; the anatomy of urinary bladder along with its relations is well recorded in the chapter on urinary stones. Varieties of stones, their signs and symptoms, the method of extraction and operative complication are given in detail. Apart from the above, surgery of intestinal obstruction (baddha-gudodara), perforated intestines (chidrodara), accidental injuries to abdomen (assaya-bhinna) in which protrusion of omentum occurs are also described along with their management.
Susruta lays down the basic principles of plastic surgery by advocating a proper physiotherapy before the operation and describes various methods or different types of defects, viz., (1) release of the skin for covering small defects, (2) rotation of the flaps to make up for the partial loss and (3) pedicle flaps for covering complete loss of skin from an area. He has mentioned various methods including sliding graft, rotation graft and pedicle graft. Nasal repair or rhinoplasty has been described in greater detail, which to this day has stood the test of time and is mentioned as the Indian method of rhinoplasty in the books of plastic surgery. Lastly, labioplasty too has received his attention. In short, all the principles of plastic surgery, viz., accuracy, precision, economy, haemostasis and perfection find an important place in Susruta’s writings on this subject.
Surgical science – Salyantantra – embraces all processes aiming at the removal of factors responsible for producing pain or misery to the body or mind. Health is, according to Susruta, a state of physical and mental well-being brought about and preserved by the maintenance of humours, good nutrition, proper elimination of waste products and a pleasant harmony of the body and the mind.
Susruta warns that improper intervention with surgical manoeuvre due either to ignorance of the progress of the disease-process, greed for money or lack of judgement, lead only to complications. A conscientious surgeon, on the other hand, considers his patient as a whole. For diseases divorced from patients are abstractions from reality. Any surgical manoeuvre is a phased programme planned well and then executed. The pascatkarman included the rehabilitation and removal of complications.
When we see today’s commercialisation of medical science, we are reminded of the ancient surgeons who maintained the nobility of their profession. Susruta says there can be nothing more magnificent than the act of removing human suffering. The science of life in practice is godly, life giving; indeed it is virtue and fame personified.