SUSRUTA, THE  FATHER  OF  SURGERY

"Surgery is the first and the highest division of the healing art, pure in itself, perpetual in its applicability, a working product of heaven and sure of fame on earth"

So said Susruta, almost 2,500 years ago.

"To Susruta may be attributed the glory of elevating the art of handling a lancet or forceps to the status of a practical science"

So wrote K.K. Bhishagratna, an acknowledged authority on the life and accomplishments of Susruta.

Frank McDowell, wrote in his "The source book of plastic surgery", "Through all of Susruta's flowery language~ incantations and irrelevances, there shines the unmistakable picture of a great surgeon. Undaunted by his failures, unimpressed by his successes, he sought the truth
unceasingly and passed it on to those who followed.  He attacked disease and deformity definitively, with reasoned and logical methods.  When the path did not exist, he made one"

                                                                                 
                                                                                    Susruta's statue in Patanjali Yogpeeth, Haridwar

While there is considerable confusion about the period in which Susruta (also called Sushruta) lived and practiced surgery, there is no question about his achievements in the field of surgery.  This is because he left a great treatise on surgery, collectively called "Sushruta
Samhita".  Reports of the age of Sushruta vary from 900 BCE to 100 CE.  The most authoritative of these is popularly called the "Bower Manuscript", and it places his age to the 5th century BCE or earlier. If this is accurate, Sushruta lived and practiced surgery around 150 years before Hippocrates, who is widely considered the Father of Medicine by Western scholars.  This fact will make Sushruta the Father of Surgery, not only in Indian Medicine but internationally.  The "Bower Manuscript", written in Sanskrit language, was discovered by Lieutenant H. Bower, in
Kuchar, in Eastern Turkestan.  It mentions Susruta, and Susruta Samhita and is widely considered by scholars as being authoritative.

                                                                        
This is an artist's rendition of Susruta performing an earlobe reconstruction
From: http://www.ispub.com/journal/the-internt-journal-of-plastic-surgery/volume-4-number- 2/sushruta-the-first-plastic-surgeon-in-600-b-c.article-g04.fs.jpg

Susruta Samhita, a comprehensive compendium on surgery written by Susruta, is known to have been translated into the Arabic language as "Kitab-i- Susrud" in the 8th Century CE on the order of Caliph Mansur; the latter was then translated into latin.  It deals in considerable detail with not only many fields of surgery but also with many allied fields; thus, descriptions are made of anatomy and embryology, obstetrics, anaesthesiology, preparation of patients for surgery and description of many surgical instruments.  Also included are the descriptions of 1120 illnesses and the application of inspection, palpation and auscultation in diagnosing those illnesses.  Many of the surgical procedures described by Susruta and the use of anesthesia for preparing the patients, predate such procedures in the West and the rest of the world by almost two millennia!  Susruta even described in some detail the code of conduct of practitioners of medicine and surgery.  This is quite akin to the famous "Hippocratic Oath", which forms the basis of the code of conduct for practitioners of Western medicine.  Scholars who have followed Susruta's contributions in the fields of plastic surgery and even neurosurgery come away with admiration for this great surgeon of antiquity.  I will enumerate some of the significant contents of Susruta Samhita below:

  1. Surgical Procedures: There are detailed descriptions of the surgical techniques for making incisions and excisions, for probing and extraction of foreign bodies, teeth extraction, use of trocars for draining abscesses and fluid from hydroceles and the peritoneum.  Other surgical procedures were prostatectomy, hernia surgery and surgery for intestinal obstruction.
  2. Orthopedic procedures: Treatment of joint dislocations {sandhimukta) and treatment of fractures (kanda-bhagna).  Also, other aspects of orthopedic treatments such as traction, manipulation and stabilization and even use of prosthetics have been described by Susruta.
  3. Obstetrical Procedures: Most prominent among the obstetrical procedures is the socalled "Caesarean section" for difficult deliveries.  Of course, this description predated Caesar by centuries!
  4. Plastic surgical procedures: Susruta described various techniques in plastic surgery, such as sliding graft, rotation graft and pedicle graft. Reconstruction of nose (often injured or lost in wars or cut off as a form of punishment for certain crimes) or 'rhinoplasty' is one of the plastic surgical procedures for which Susruta is famous.
  5. Urological procedures: Susruta described the varieties of urinary system stones and methods of extraction of the stones.
  6. Medical ethics: The students were required to take a solemn oath of conduct at the onset of training ; this training lasted 6 years. It is worth noting here that this oath of conduct preceded the "Hippocratic Oath" by at least one or two centuries.  These injunctions went farther than the Hippocratic Oath, in that, the teachers were required to abide by strict code of conduct as well. A partial list of the required actions in the solemn oath of the students included: " .... renounce lust, anger, greed, ignorance, vanity, selfishness, envy, rudeness, miserliness, falsehood, sloth and all other acts that bring a man to disrepute.  At the proper time, you must clip your nails and trim your hair, and put on the saffron robe of the student. You must live the truthful, disciplined life of a student and obey and respect your teacher.  At rest, asleep or awake, at meals, at study and in all your acts, at all times you must be guided by my instructions.  All actions should be pleasant and beneficial to me, otherwise your knowledge and study will be ineffective and you will never achieve fame".  (The foregoing is a quotation from the article on Susruta in South African Medical Journal: B. Singh and Swami Saradananda, Ethics and surgical training in ancient India- a cue for current practice: SAMJ 98:3, March 2008)
  7. Physiotherapy, preparation for surgery and anesthesia: These were used as part of the armamentarium of surgeons by Susruta. It is noteworthy that the use of such procedures predated their use in the West by almost two Millennia. It is mind-boggling to realize that Susruta performed intricate surgeries, which included not only plastic surgery but also operations on the eye and even neurosurgery.

The following are selected quotations from Susruta Samhita, to highlight the style and substance of his teachings. They will also show that at least a Millennia before Galen and Vesalius, this master surgeon practiced surgery rooted in scientific knowledge of anatomy.  He wrote, " .... the practice can be started only after having read and thoroughly studied the science of medicine; having seen and performed the operation himself; having passed the appropriate tests and thence obtained the permission of the governing authority".  "He who knows theory only but is not so good in practical work, gets bewildered on being confronted with a patient, in the same way as a coward feels on the battlefield". On the qualities of a good surgeon, he explained : "Boldness, swiftness, sharpness of instruments, no sweating or trembling of hands and confidence are the qualities of a surgeon at the time of operation".  "The surgeon who knows the structures of all the body cannot be misled into errors of anatomical ignorance". He continued: " ... only he can be considered an expert surgeon who is well versed in the practical and descriptive
anatomy.  Therefore, one should start the procedures after clearing away the doubts by actually seeing the surgical anatomy concerned and consulting the appropriate literature". " A person who studies one branch of science cannot arrive at proper conclusions, therefore, a physician should try to learn as many sciences as possible".  " In order to broaden your knowledge and outlook, you should study the subject regularly, take part in scientific debates and discussions, observe the allied sciences and take training from specialists of those branches."

The following are Susruta's instructions about the students learning the craft of surgery: 11 the art of making specific forms of incisions should be taught by cuts in the body of a pushpaphala ( a type of gourd), a watermelon or a cucumber ... the art of making cuts in an upward or downward directions should be similarly taught. The art of making excisions should be practically demonstrated by making openings in the body of a bull water bag or in the bladder of a dead animal. The art of scraping should be instructed on a piece of skin on which the hair has been allowed to remain. The art of venesections should be taught on the vein of a dead animal or with the help of a lotus stem. The art of extracting by withdrawing seeds from the kernel of a nimbi or jack fruit. The art of bandaging or ligaturing should be practically learnt by tying bandages around the specific limbs or members of a full-sized doll of stuffed linen. The art of cauterizing or applying alkaline preparations should be demonstrated on a piece of soft flesh. Lastly, the art of inserting syringes and injecting enemas into the regions of the bladder or into an ulcerated channel, should be taught by asking the pupil to insert a tube into a lateral fissure of a pitcher full of water or into the mouth of a gourd."

Finally, I will end with an appropriate quotation from the authors of the article in South African Medical Journal (see Bibliography below), as it pays tribute to Susruta's vision, which transcends time.  "The philosophy behind the training and teaching of surgical skills to surgeons in the era of ancient India resonates with modern trends in surgical education, and is strongly reminiscent of present- day courses such as basic surgical skills and laparoscopic workshops~ thus underscoring the view that innovations are seldom truly original. The accountability of the teacher for unacceptable practices~ and of the doctor to "the government" is analogous to the role of present-day professional controlling bodies, thus demonstrates a remarkable vision and deserves great admiration".

I will end this essay with diagrams of the various surgical instruments Susruta had devised and used.

SURGICAL INSTRUMENTS POPULARIZED BY SUSRUTA:

                                                                    

BIBLIOGRAPHY:

1) B. Singh and Swami Saradananda, Ethics and surgical training in ancient India- a cue for
current practice. SAMJ March 2008, 98:3, pp 218-22
2) http://en.wikipedia.org/wiki/Sushruta Samhita
3) http:/www.ispub.com/journal/the-internet-journal-of-plastic-surgery/volume-4-number-
2/sushruta-the-first-plastic-surgeon
4) http://www.plastangel.com/ancient-indian-plastic-surgery.html
5) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2845368/
6) http://www .infinityfoundation .com/mandala/t_ es/t_ es agraw _susruta .htm

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