Sushrutha is recognized today as the ‘Father of Plastic Surgery’ all over the world. The fact that such a man in flesh and blood performed these surgeries a millennium before Hippocrates and two millenniums before European stalwarts like Celsius and Galen ever appeared on the scene is hard for most to realize and appreciate.
Sushruta Samhita (सुश्रुतसंहिता) is a Sanskrit text on surgery, attributed to Sushruta, a physician who possibly resided in Varanasi around 6th century BCE. Susrutha-Salya-Tantra were composed about 6th century B.C. It has been revised by Nagarjuna in the later part of 4th century BCE. This text, along with the Charaka Samhita, is considered as foundational texts of Ayurveda (Indian traditional medicine). The text was translated to Arabic as Kitab-i-Susrud in the 8th century CE.
The plastic in plastic surgery actually has its root in the Greek word plastikos meaning to give something shape or form. Evidence exists that cosmetic surgery was done by ancient physicians in India eight centuries before Christ.
The word Rhino came from Rhonoceros with large horn above its nose. There were a surprisingly large number of noses in India that needed to be reconstructed. Noses were considered symbols of pride, therefore they proved to be quite tempting targets during warfare. Besides the multiple damages to Indian noses as a result of warfare, other noses required surgical repair following the damage brought on by punishment for legal transgressions. Amputation of the nose was considered proper and just punishment for a multitude of offenses, including adultery.The roots of ancient Indian surgery go back to more than 4000 years ago.
Sushrutha, one of the earliest surgeons of recorded history (600 BCE) is believed to be the first individual to describe Rhinoplasty. The detailed description of the Rhinoplasty operation by Sushrutha is amazingly meticulous, comprehensive and relevant today.
‘Sushrutha Samhitha’ is considered to be the most advanced compilation of surgical practices prevalent in India around two thousand millennia ago. In his book, Sushruta emphasized all the basic principles of plastic surgery and vividly described numerous operations in various fields of surgery with significant contributions to Plastic Surgery.
Sushruta describes the (modern) free-graft Indian rhinoplasty as the Nasikasandhana.
In its current form, The Sushruta Samhitais a redaction text comprising 184 chapters, describing 1120 illnesses, 700 medicinal plants, 64 preparations from mineral sources and 57 preparations based on animal sources.
The text discusses surgical techniques of making incisions, probing, extraction of foreign bodies, alkali and thermal cauterization, tooth extraction, excisions, and trocars for draining abscess draining hydrocele and ascitic fluid, the removal of the prostate gland, urethral stricture dilatation, vesiculolithotomy, hernia surgery, caesarian section, management of haemorrhoids, fistulae, laparotomy and management of intestinal obstruction, perforated intestines, and accidental perforation of the abdomen with protrusion of omentum and the principles of fracture management, viz., traction, manipulation, appositions and stabilization including some measures of rehabilitation and fitting of prosthetics. It enumerates six types of dislocations, twelve varieties of fractures, and classification of the bones and their reaction to the injuries, and gives a classification of eye diseases including cataract surgery.
The Sushruta Samhita is divided into two parts. The first is the five section Purva-tantra, and the second is the Uttara-tantra. Together, the Purva-tantra and Uttara-tantra (apart from Salyya and Salakya) describe the sciences and practices of medicine, pediatrics, geriatrics, diseases of the ear, nose, throat and eye, toxicology, aphrodisiacs and psychiatry.
- The Purva-tantra is dedicated to the four branches of Ayurveda. It is divided into five books and 120 chapters (It is noteworthy that the Agnivesa-tantra, better known as the Charaka Samhita and the Ashtanga Hridayam of Vagbhata, is also divided into 120 chapters). These five books are the Sutra-sthana, Nidana-sthana, Sarira-sthana, Kalpa-sthana and Chikitsa-sthana. The Nidana-sthana is dedicated to aetiology, the signs and symptoms of important surgical diseases and those ailments which have a bearing on surgery. The rudiments of embryology and the anatomy of the human body, along with instructions for venesection, 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. The Chikitsa-sthana describes the principles of management of surgical conditions, including obstetrical emergencies, including chapters on geriatrics and aphrodisiacs. The Kalpa-sthana is mainly Visa-tantra, dealing with the nature of poisons and their management.
- The Uttara-tantra contains the remaining four specialities, namely Salakya, Kaumarabhfefefrtya, Kayacikitsa and Bhutavidya. The entire Uttara-tantra has been called Aupadravika, since many of the complications of surgical procedures as well as fever, dysentery, cough, hiccough, krmi-roga, pandu, kamala, etc., are briefly described here. The Salakya-tantra portion of the Uttara-tantra describes various diseases of the eye, the ear, the nose and the head.
How British learned Plastic Surgery from Indians
Between 1769 AD to 1799 AD, four Mysore Wars were fought between Hyder Ali and his son Tipu Sultan and the British.
During these wars the British learnt two very important Indian techniques: Rocketry and plastic surgery.
A Maratha cart-driver, Kawasajee, who had served the British, and four tilanges (Indian soldiers of British army) had fallen into the hands of the Sultan of Srirangapattam. Their noses and right arms were cut off as a punishment for serving the enemy. Then they were sent back to the English command.
After some days, when dealing with an Indian merchant, the English commanding officer noticed that he had a peculiar nose and scar on his forehead. On inquiry, he learnt that the merchant’s nose had been cut off as a punishment for adultery and that he had a substitute nose made by a Maratha Vaidya of the kumhar (potter) caste. The commanding officer sent for the Vaidya and asked him to reconstruct the nose of Kawasajee and others.
The operation was performed near Pune in the presence of two English doctors, Thomas Cruso and James Findlay. An illustrated account of this operation, carried out by an unnamed Vaidya, appeared in the Madras Gazette. Subsequently, the article was reproduced in the Gentleman’s Magazine of London in October 1794. The operation is described as follows :
“A thin plate of wax is fitted to the stump of the nose so as to make a nose of good appearance; it is then flattened and laid on the forehead. A line is drawn around the wax, which is then of no further use, and the operator then dissects off as much skin as it had covered, living undivided a small slip between the eyes. This slip preserves the blood circulation till a union has taken place between the new and the old parts.
The cicatrix of the stump of the nose is next paired off, and immediately behind the new part, an incision is made through the skin which passes around both alae, and goes along the upper lip. The skin, now brought down from the forehead and being twisted half around, is inserted into this incision, so that a nose is formed with a double hold above and with its alae and septum below fixed in the incision. A little Terra Japonica (pale-catechu) is softened with water and being spread on slips of cloth, five or six of these are placed over each other to secure the joining. No other dressing but this cement is used for four days. It is then removed, and cloths dipped in ghee are applied. The connecting slip of skin is divided about the twentieth day, when a little more dissection is necessary to improve the appearance of the new nose. For five or six days after the operation, the patient is made to lie on his back, and on the tenth day, bits of soft cloth are put into the nostrils to keep them sufficiently open. This operation is always successful. The artificial nose is secured and looks nearly as well as the natural nose, nor is the scar on the forehead very observable after a length of time.”
This description fired the imagination of the young English surgeon J.C. Carpue, who after gathering more information on the “Indian nose” performed two similar operations in 1814 with successful results. After Carpue published his account, Graefe, a German surgeon, performed similar plastic operations of the nose using skin from the arm. After this plastic surgery became popular throughout Europe. All replacement operations which use a flap of skin in the immediate vicinity of the loss are known as Indian plastic surgery.
Surgery in India reached admirable heights during the era of Sushrutha. We are proud to have such a genius as the pioneer of our surgical heritage. The Association of Plastic Surgeons of India celebrates his life and time by giving him a proud position in the association’s emblem!