History of Surgerychapter 1

Quoting Herodotus: The practice of medicine is very specialized among Indians. Each physician treats just one disease. The country is full of physicians, some treat the eye, some the teeth, some of what belongs to the abdomen, and others internal diseases.

The art of surgery in Indian medicine is known as Salyatantra. Originating from foreign bodies of all origins denoted as Salya, especially the arrows which was the most common and most dangerous foreign body causing wounds and requiring surgical treatment (Salya—broken parts of an arrow and such other sharp weapons; tantra—maneuver).

Sushruta was a great surgeon of ancient India, though there is considerable controversy about his age. Sushruta is stated to be the son of Vishvamitra in the Sushruta Samhita.2

Surgery was widely used in Indian medicine. In the ancient World, Indian surgeons performed the most elaborate operations. Over 121 different steel instruments (Fig. 1.2) were used to sew-up wounds, drain fluid, remove kidney stones and to perform plastic surgery. An official punishment for adultery was to cut-off your nose, so surgeons had plenty of opportunities to reconstruct and refine noses.

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.

Sushruta the father of Indian Surgery (Fig. 1.1) is the author of the Sushruta Samhita, the work known after his name, and one of the most authentic reference in Indian medical literature. There are references to accidental loss of leg of Vispala who was immediately provided an iron leg-prosthesis to walk with.3

The Rigveda mentions many a surgical feat of the celestial twin medical experts, The Ashvins. Amongst the eight divisions of medical knowledge (Ayurveda), surgery was considered the first and the most important branch.

As early as 1200 BC, Agnivesha took the Herculean task of gathering, pruning, emphasizing and compiling the Kalpas, small monographs into textbooks of medicine. As most of the references on ancient medicine and surgery were in form of Kalpas.

The ancient Indian medical practitioners were categorized into either: the Salya-cikitsakas (surgeons) or the Kaya-cikitsakas (physicians). Surgery had not yet been incorporated into the encyclopedic tradition as represented by the Agniveshatantra. Sushruta had put in lot of efforts to get surgery achieve a leading position in general medical training.

Sushruta Samhita, the composition of Sushruta, known after his name, is the transalation of what he learnt at the feet of his preceptor Divodasa Dhanvantari. There are references that along with Sushruta, Aupadhenava, Vaitarana and others too had their instruction from Divodasa Dhanvantari and they also had with their own limitations prepared a treatise on Salyatantra. Amongst these compositions, only the Sushruta Samhita has remained the only treatise for two of the eight branches of Ayurveda, namely Salya and Salakya.

The progress of internal medicine saw a steep rise, where as surgery declined and was ultimately practiced by some traditional families, and the knowledge was limited to theory only. The reason being:

The Sushruta Samhita is in two parts: The Purvatantra in five sections and the Uttaratantra. These two parts together cover—Salya and Salakya, the main essence of the Samhita. 5

7Along with other specialties like medicine, pediatrics, geriatrics, diseases of the ear, nose, throat and eye, toxicology, aphrodisiacs and psychiatry.

Though the Sushruta Samhita is compilation of the science of surgery, it also incorporates the relevant aspects of other disciplines too. Because Sushruta himself was of the opinion that if you want to master your faculty you should have sound knowledge of allied branches.

The Samhita consists of five books in an encyclopedia:

The Nidana-sthana that provides knowledge of etiology, signs and symptoms of important surgical diseases and those ailments, related to surgery.

The Sarira-sthana which provides knowledge of 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) along with the essentials of obstetrics.

The Cikitsa-sthana deals with the principles of management of surgical conditions including obstetrical emergencies along with a few chapters on geriatrics and aphrodisiacs.

Needing special mention is Uttaratantra also named Aupadravika briefly dealing with a lot of complications of surgical procedures like fever, dysentery, cough, hiccough, kurmi-roga, pandu, kamala, etc.

Sushruta was always of the opinion that anyone who wants to master surgery should study anatomy by practical observation of the various structures composing the body. This is dealt with in detail in the Sarira-sthana of the Sushruta Samhita. He practiced a phasewise approach to study embryology before anatomy and in those prehistoric days he recommended human body dissection.

8Sushruta in his book, has described over 120 blunt and sharp surgical instruments, (Fig. 1.2) 300 surgical procedures and classifies human surgery into eight categories. He was of the feeling that a surgeon, by his own experience and intelligence, may invent and add new instruments to make surgical procedures simpler. There is also a mention of 14 types of bandaging capable of covering almost all the regions of the body are described for the practice of the student on dummies. Procedures of surgical importance in modern surgery like cauterization by Ksharas (alkaline substances) or Agni and application of leeches were used abundantly. Thermal cauterization for therapeutic purposes has been advocated by heating various substances and applying them at the desired sites.

Sushruta has described surgery under eight heads: (Fig. 1.3)