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Surgical procedures in Sushruta-Samhita: A conceptual study

Posted on March 12, 2013 by Vaidya Shital D. Londhe

9

SURGICAL PROCEDURES IN SUSHRUTA SAMHITA- A CONCEPTUAL STUDY
Introduction:
Ayurveda is the ancient system of medicine which originated thousands of years back, is the only discipline that promises to be fully secular and contains clear potential of modern
understanding of natural science. Ayurveda is considered to be the first medical record of ancient knowledge and civilization in the world. Ayurveda specialized into 8 branches, out of which shalya tantra represents surgical treatment. The Sushruta Samhita is an ayurvedic text by legendary Sushruta foundational to ayurvedic medicine, with innovative chapters mainly on surgery. Sushruta was primarily a surgeon and recognized as the ‘Father of Surgery’ in the world. He mentioned various surgical procedures, out of which some examples of surgical techniques performed by him are narrated in brief here.

Aim:
To review the various surgical concepts of Sushruta Samhita and correlate with modern
technological steps of surgery.
Material and Methods:
All sorts of references has been collected and compiled from Ayurvedic classics and
commentaries like Sushruta Samhita, Dalhan tika etc. We have also referred modern text books of surgery like Bailey and Love, K. Das etc.and also searched various websites of surgery.

Observations:
By the study it elucidates this fact that Sushruta Samhita is a comprehensive treatise on the entire medical discipline with special attention to shalya and shalakya tantra. He had performed many surgeries covering all fields of surgiacal branches like general surgery, eye, ENT, obstetrics, urology, orthopaedics etc. Some examples of surgical techniques performed by him are narrated in brief here.

•  Ashtavidha Shastrakarma (Basic surgical procedures):

Sushruta describes 8 types of surgical procedures viz.; Chedana (Excision), Bhedana (Incision), Lekhana (scrapping), Aharana (Extraction), Vedhana (puncturing),Eshana (probing), Sivana (Stitching).

• Nasa Sandhana (Rhinoplasty):This is reconstructive surgery of nose first mentioned by Sushruta and established as a milestone in the field of plastic surgery.
•  Karna Sandhana (Lobuloplasty): Reconstructive surgeries of ear lobule in the various defects either caused by congenital or traumatic reasons.15 techniques of repair of torn ear lobules (lobuloplasty) had been given by Sushruta.
•  Ostha Sandhana (Repair of hare lip):The description of repair of deformed lip is given in the same chapter as such as given for nasa sandhana.
•  Karna vedhana (Ear puncture): The piercing of children ear lobe with a needle or awl on an auspicious day and time with hymn is known as karna vedhana samskar. (custom).
•  Anorectal surgerical techniques: Different types of incisions to remove fistulous tract as Langalaka (T shaped), Ardhalangalak (L shaped), Sarvatobhadrak (circular), Gotirthak (half moon), Kharjurpatrak (serrated).
•  Urological techniques: Varieties of stones and method of extraction (by perineal lithotomy) and operative complications were given in detail. Post operative wound management may be the first reference of surgical management of calculus in history of surgery.
•  GIT procedures: Intestinal sutures for Baddhagudodara, chhidrodara (perforated intestines), injuries to ashaya(abdomen) are also described along their management.
• Asthisandhi bhagna chikitsa (Management of fracture/displacement of bones & joints): He classifies and gives 6 types of dislocations and 12 varieties of fractures. He gives principles of fracture treatment i.e. traction, manipulation, stabilization. Same method is still practiced in modern orthopedics.
• Parasurgical procedures: Kshara, agni and jalauka are used as para surgical procedures in ayurvedic surgical science for various ailments. Mainly for musculoskeletal disorders, several forms of thermal cauterization by agni karma is advocated. Kshara (caustic alkali) used to stop bleeding, healing of an ulcer, necrose the haemorrhoids, cutting the fistula tract.

Jaluaka are used for various rakta dushtikar vyadhis (haematological disorders).

Discussion:
The surgical procedures given by Sushruta are in the basic form and still relevant to
modern counterpart. The various plasties are popular in these days also and advancement
in the methodology is based on Sushruta’s method. Sushruta knows every step of any
surgical techniques and his vision regarding every aspect was clear.

Conclusion:
The technique of various surgical procedures described in Sushruta Samhita is
eminently in line with technical abilities of time. The parasurgical procedures are gaining
popularity now a days. The need of hour to establish various superspecialties of Shalya
Tantra in order to bring back the glory which has lost decades ago. The technical
refinements of surgical skills are possible and it should be evolved.
References:
1.Sushruta Samhita, Nibandha Sangraha & commentary by Dalhan, Yadavji T,
Chaukhmaba Sanskrit Samsthan.
2.Bailey & Love’s Short Practice of Surgery, 25th edition, Norman S.Williams etc.
3.Internet websites.


Author: Dr.Shital D.Londhe (PG Scholar Shalya Tantra)
Guide: Prof. Dr. T. Srinivas (MD Shalya Tantra)
Yashwant Ayurvedic College,PGT & RC, Kodoli.

rhinoplasty

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Our Scientific Heritage :
Plastic Surgery in Ancient India
-Gunakar Muley

From 1769 AD to 1799 AD, in a period of thirty years, four Mysore Wars were fought between Hyder Ali and his son Tipu Sultan and the British. As a result of these wars the British learnt two very important Indian techniques --- rocketry and plastic surgery. Both these Indian techniques were further improved first in England and then in other European countries (see 'Story of Indian Rockets', DREAM, October 1999). How the British learnt the art of Indian plastic surgery is a fascinating story.

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.

Plastic surgery has little to do with plastics, the synthetic substances so common today. The term 'plastic', derived from the Greek plastikos, means to mould or shape. The task of plastic surgery is to restore the appearance and function of parts of the body destroyed or damaged by disease or injury. Contrary to popular belief, plastic or reconstructive surgery is not merely cosmetic surgery but an important discipline that aims at correcting all sorts of physical deformities. Though a very old technique, plastic surgery has made great strides only after the First World War.

The Bible contains no reference of plastic operations. There is no mention of plastic surgery in the ancient Greek literature. Homer (9th century BC) has described various types of wounds and their treatments but did not mention the possibility of replacing parts of the nose or other features. Roman legends vaguely mention plastic surgery. Genuine records of plastic operations are not found in Europe until the middle of the fifteenth century. These come from Italy. Many European scholars are of the opinion that reports of Indian plastic operations reached Italy by way of seamen and merchants, who used to undertake long journeys to the Far East at the beginning of the Middle Ages. Like other methods Indian mathematics and medicine, the Italians might have learnt the techniques of Indian plastic surgery from the Arab Moors.

From Italy we have the record that in 1442, Branca, a surgeon of Catania in Sicily, carried out plastic operations of the nose, using flap from the face. His son Antonio continued his work and was the first to use a flap from the arm for reconstructing the nose. The work was carried on by the Boinias, another Italian family. The plastic operations carried out by the Boinia brothers are described in a book published in 1568 by Fioravanti, a doctor of Bologna.

However, it was in the hands of Gasparo Tagliacozzi (1546-99), a professor of surgery and of anatomy at the Bologna University, that plastic surgery attained wide fame in Europe. His book De curtorum chirurgia per insitionem (The surgery of defects by implantation), printed in 1597, was the first scientific treatise on plastic surgery. Tagliacozzi has described a method of plastic substitution of the nose by skin from the arm and of replacement of the ears and lips, demonstrating his work by a large number of illustrations.

The Church dignitaries regarded plastic surgery as an interference in the affairs of the Almighty. They not only excommunicated Tagliacozzi but later got his corpse exhumed from its church grave and placed in an unconsecrated ground !

In the 17th and 18th century not much importance was attached to plastic surgery in Europe. The great Voltaire (1694-1778) wrote a satirical poem on Tagliacozzi and his operation on the nose, using flap from the buttocks. Many gentlemen who lost their nose in duel or through other misfortunes had substitutes made of gold, silver or ivory. The Danish astronomer Tycho Brahe (1546-1601) once became involved in a dispute with another young Danish nobleman over who was the better mathematician. The dispute led to a duel in which Tycho lost part of his nose. This he replaced with a mixture of gold, silver, and wax, of which he was very proud.

In ancient Europe, as we have seen, there was no tradition of plastic operations.
The plastic operation on nose done by Branca in 1442 was very similar to the one described in the Sushruta-Sanhita, an Ayurvedic compendium composed in the early centuries of the Christian era. In India, from ancient times to the early nineteenth century, we find a living tradition of plastic operations of the nose, ear and lip. The Kangra (correctly pronounced as 'Kangada') district in Himachal Pradesh was famous for its plastic surgeons. Some scholars are of the opinion that the word 'Kangada' is made from 'Kana + gadha' (ear repair). The British archaeologist Sir Alexander Cunningham (1814-93) has written about the tradition of Kangra plastic operations. We have information that in the reign of Akber a Vaidya named Bidha used to do plastic operations in Kangra.

The Charaka-Sanhita and the Sushruta-Sanhita are among the oldest known treatise on Ayurveda (the Indian science of medicine). Chronologically, Charaka-Sanhita is believed to be an earlier work, and deals with medicine proper containing a few passages on surgery. The Sushruta-Sanhita, a work of the early centuries of the Christian era, mainly deals with surgical knowledge. The extant Sushruta-Sanhita is, according to its commentator Dalhanacharya (twelth century AD), a recension by Nagarjuna. The original Sushruta-Sanhita was based on a series of discourses of Kashiraj Divodas (or Dhanvantari) to his disciples, Sushruta and others.

There has been a tradition to divide the Ayurveda works into 120 chapters. The Susruta Sanhita also contains 120 chapters, grouped into five sthanas (books): Sutrasthana, Nidanasthana, Sharirasthana, Chikitsashana and Kalpasthana. Besides, the compendium contains an appendix, called Uttaratantra, consisting of 66 chapters.

The plastic operations of otoplasty (plastic surgery of the ear) and rhinoplasty (plastic surgery of the nose) are described in the 16th chapter of the first book (Sutrasthanam) of the compendium. First, methods are described for piercing the ear-lobes of an infant which still is a widespread practice in India. Often these ear-lobes, due to the use of heavy ornaments, get considerably expanded and ultimately sunder. Sushruta has described 15 methods of joining these cut-up ear-lobes. For these plastic operations, called Karnabandha, a piece of skin was taken from the cheek, turned back, and suitably stitched on the lobules. Further treatment of the operation, periodic dressing of the wound and the use of various ointments is elaborately described.

In describing the method of rhinoplasty (Karnabandha), Sushruta says that the portion of the nose to be covered should be first measured with a leaf . Then a piece of skin of the required size should be dissected from the living skin of the cheek, and turned back to cover the nose, keeping a small pedicle attached to the cheek. The part of the nose to which the skin is to be attached should be made raw by cutting of the nasal stump with a knife. The physician then should place the skin on the nose and stitch the two parts swiftly, keeping the skin properly elevated by inserting two tubes of eranda (the castor-oil plant) in the position of the nostrils, so that the new nose gets proper shape. The skin thus properly adjusted, it should then be sprinkled with a powder composed of liquorice, red sandal-wood and barberry plant. Finally, it should be covered with cotton, and clean sesame oil should be constantly applied to it. After some days the wound heals up and the grafting is successful. Sushruta also mentions the reconstruction of the broken lip and hare-lip (Oshtha-sandhana).

Thus, plastic surgery is a very old science. It is, however, difficult to say when the first plastic operations on man were performed. Primitive man knew how to do grafting in plants. This might have given him the idea of transferring tissues in man and animals. The necessity arose when he lost such parts of his body as the nose, which has been a common form of injury in all periods of history. In olden days, removal of the nose was also one of the most common form of punishment. Manu, the famous lawgiver, mentions the ears and the nose among the ten parts of the body on which punishments are to be executed (Manusmruti : 8.125), Thus it became a social necessity to find a substitute for the lost nose. The development of plastic surgery is closely connected with the operative techniques used in the field known as rhinoplasty.

After getting fresh impetus from India, plastic surgery has made great progress in the past two hundred years. In 1933 the first international congress of plastic surgery was held in Paris. Basically, the task of plastic surgery is to restore the parts of the body destroyed or damaged by disease or injury. But in recent years "cosmetic surgery" as beauty treatment has become very fashionable. Anyway, we should always remember that the sources of modern plastic surgery are the Sushruta-Sanhita and it was from India the Europeans learnt the technique of rhinoplasty.

Illustrations : 1. In 1793, a Maratha Vaidya reconstructed the nose of a cart-driver. Illustration from "Gentleman's Magazine" (London), Oct.1794. 2. Italian method of plastic surgery of the nose taking flap from the arm (two illustrations from Tagliacozzi's work).

3. Present type of Indian flap from forehead used for nasal plastic surgery.
4. Sushruta doing plastic surgery of the ear.
5. Some surgical instruments (Yantra and Shastra) as described in the 
Sushruta-Sanhita.

shushruta

Sushruta: The first Plastic Surgeon in 600 B.C.

S Saraf, R Parihar

http://ispub.com/IJPS/4/2/8232

Keywords

indian rhinoplasty method, sushruta

Citation

S Saraf, R Parihar. Sushruta: The first Plastic Surgeon in 600 B.C.. The Internet Journal of Plastic Surgery. 2006 Volume 4 Number 2.

Abstract

Sushruta, one of the earliest surgeons of the recorded history (600 B.C.) is believed to be the first individual to describe plastic surgery. Sushruta who lived nearly 150 years before Hippocrates vividly described the basic principles of plastic surgery in his famous ancient treatise 'Sushruta Samhita'
1,2 in 600 B.C. 'Sushruta Samhita'(Sushruta's compendium) which is one of the oldest treatise dealing with surgery in the world indicates that he was probably the first surgeon to perform plastic surgical operations. This paper presents a historical window into various contributions of Sushruta to plastic surgery and allied fields which were described in 'Sushruta Samhita' more than 2500 millennia ago.

 

Although many people consider Plastic Surgery as a relatively new specialty, the origin of the plastic surgery had his roots more than 4000 years old in India, back to the Indus River Civilization. The mythico-religious shlokas (hymns) associated with this civilization were compiled in Sanskrit language between 3000 and 1000 B.C. in the form of Vedas, the oldest sacred books of the Hindu religion. This era is referred to as the Vedic period (5000 years B.C) in Indian history during which the the four Vedas, namely the Rigveda, the Samaveda, the Yajurveda, and the Atharvaveda were compiled. All the four Vedas are in the form of shlokas (hymns), verses, incantations and rites in Sanskrit language.3 ‘Sushruta Samhita' is believed to be a part of Atharvaveda. 4

‘Sushruta Samhita'(Sushruta's compendium), which describes the ancient tradition of surgery in Indian medicine is considered as one of the most brilliant gems in Indian medical literature. This treatise contains detailed descriptions of teachings and practice of the great ancient surgeon Sushruta (Figure-1) which has considerable surgical knowledge of relevance even today.

Figure 1

Figure 1: Sushruta (600 B.C.)

The ‘Sushruta Samhita' contains the major surgical text of the Vedas and is considered to be the most advanced compilation of surgical practices of its time. ‘Sushruta Samhita' encomprises not only the teaching regarding the plastic surgery but contains composite teachings of the surgery and all the allied branches including midwifery and making it a comprehensive treatise on the entire medical discipline. Sushruta believed that knowledge of both surgery and medicine are essential to constitute a good doctor who otherwise “is like a bird with only one wing.” In fact, Sushruta emphasized 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. According to Sushruta, “Any one, who wishes to acquire a thorough knowledge of anatomy, must prepare a dead body and carefully observe and examine all its parts”. The method of study was to submerge the body in water and allow it to decompose followed by examination of the decomposing body at intervals to study structures, layer by layer, as they got exposed following decomposition. The most important point to note here is that the dissection was performed without using knife.

The exact period of Sushruta is unclear but most scholars put him him between 600 to 1000 BC.5,6,7,8 Sushruta lived, taught and practiced his art in the area that corresponds presently to the city of Varanasi (Kashi, Benares) in northern part of India. Varanasi, on the banks of the Ganges is one of the holiest places in India and is also the home of Buddhism and Ayurveda, one of the oldest medical disciplines. The followers of Sushruta were called as Saushrutas. The new student was expected to study for at least 6 years. Before starting his training he had to take a solemn oath, which can be compared to that of Hippocrates.9,10 He taught the surgical skills to his students on various experimental modules, for instance, incision on vegetables (like watermelon, gourd, cucumber etc.), probing on worm eaten wood, preceding present day workshops by more than 2600 years.(Figure-2)

Figure 2

Figure 2: ‘‘Saushrutas'‘ doing mock surgeries on gourds, watermelons, cucumbers

This master literature remained preserved for many centuries exclusively in the Sanskrit language which prevented the dissemination. of the knowledge to the west and other parts of the world. Later the original text was lost and the present extant one is believed to be a revision by the Buddhist scholar Vasubandhu (circa AD 360-350). In the eighth century A.D., ‘Sushruta Samhita' was translated into Arabic as Kitab-Shaw Shoon-a-Hindi and Kitab-i-Susrud. The translation of ‘Sushruta Samhita' was ordered by the Caliph Mansur (A.D.753 -774).11 One of the most important documents in connection with ancient Indian medicine is the Bower Manuscript, a birch-bark medical treatise discovered in Kuchar (in Eastern Turkistan), dated around AD 450 and is housed in the Oxford University library.12 The first European translation of ‘Sushruta Samhita' was published by Hessler in Latin and into German by Muller in the early 19th century. The first complete English translation was done by Kaviraj Kunja Lal Bhishagratna in three volumes in 1907 at Calcutta.1

The treatise's insight, accuracy and detail of the surgical descriptions are most impressive. In the book's 184 chapters, 1,120 conditions are listed, including injuries and illnesses relating to ageing and mental illness. The compendium of Sushruta includes many chapters on the training and practice of surgeons. The Sushruta Samhita describes over 120 surgical instruments (Figure-3), 5,13 300 surgical procedures and classifies human surgery in 8 categories.

Figure 3

Figure 3: Surgical instruments as described by Sushruta

The ancient surgical science was known as Salya-tantra.Salya-tantra (surgical science) embraces all processes aiming at the removal of factors responsible for producing pain or misery to the body or mind. Salya(salya-surgical instrument) denotes broken parts of an arrow /other sharp weapons while tantra denotes maneuver. The broken parts of the arrows or similar pointed weapons were regarded as the commonest and most dangerous objects causing wounds and requiring surgical treatment. Shushruta has described surgery under eight heads Chedya(excision), Lekhya (scarification), Vedhya (puncturing), Esya (exploration), Ahrya (extraction), Vsraya (evacuation) and Sivya (Suturing).9,10

All the basic principles of plastic surgery like planning, precision, haemostasis and perfection find an important place in Sushruta's writings on this subject.Sushruta described various reconstructive methods or different types of defects like release of the skin for covering small defects, rotation of the flaps to make up for the partial loss and pedicle flaps for covering complete loss of skin from an area.14 (Figure -4)

Figure 4

Figure 4: Sushruta doing earlobe reconstruction

One of the great highlight of Sushruta's surgery was the operation of Rhinoplasty. The making of a new nose captured the imagination of the medical world and brought him fame as the originator of plastic surgery.1 The famous Indian Rhinoplasty (reproduced in the October 1794 issue of the Gentleman's Magazine of London) is a modification of the ancient Rhinoplasty described by Sushruta in 600 B.C.15 (Figure-5). Even today pedicled forehead flap is referred to as the Indian flap.

Figure 5

Figure 5: Reconstruction of the nose by forehead Rhinoplasty

Ackernecht has aptly observed -”There is little doubt that plastic surgery in Europe which flourished in medieval Italy is a direct descendant of classical Indian surgery”.5,16

In describing the method of Rhinoplasty (Nasikasandhana) Sushruta says 17:

“The portion of the nose to be covered should be first measured with a leaf. Then a piece of skin of the required size should be dissected from the living skin of the cheek, and turned back to cover the nose, keeping a small pedicle attached to the cheek. The part of the nose to which the skin is to be attached should be made raw by cutting the nasal stump with a knife. The physician then should place the skin on the nose and stitch the two parts swiftly, keeping the skin properly elevated by inserting two tubes of eranda (the castor-oil plant) in the position of the nostrils, so that the new nose gets proper shape. The skin thus properly adjusted, it should then be sprinkled with a powder of liquorice, red sandal-wood and barberry plant. Finally, it should be covered with cotton, and clean sesame oil should be constantly applied. When the skin has united and granulated, if the nose is too short or too long, the middle of the flap should be divided and an endeavor made to enlarge or shorten it.” (SS. 1.16).

Speculations have been raised as how, in the absence of anesthetics, the Indian surgeons carried out such major operations. Sushruta writes that “wine should be used before operation to produce insensibility to pain.” He again remarks: “The patient who has been fed, does not faint, and he who is rendered intoxicated, does not feel the pain of the operation.”

Sushruta considered surgery the first and foremost branch of medicine and stated1,3: “Surgery has the superior advantage of producing instantaneous effects by means of surgical instruments and appliances. Hence, it is the highest in value of all the medical tantras. It is eternal and a source of infinite piety, imports fame and opens the gates of Heaven to its votaries. It prolongs the duration of human existence on earth and helps men in successfully fulfilling their missions and earning a decent competence in life.”

Health, according to Sushruta is 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. Sushruta says there can be nothing more magnificent than the act of treating human suffering, life giving, indeed is virtue and fame personified.

He warns that improper intervention with surgical maneuver due either to ignorance of the progress of the disease-process, greed for money or lack of judgment, lead only to complications. Sushruta's general advice to physicians would certainly apply to doctors in any age and anywhere in the world: ‘‘A physician who has set out on this path should have witnessed operations. He must be licensed by the king. He should be clean and keep his nails and hair short. He should be cheerful, well-spoken and honest'‘.

The genius of Sushruta prompted eminent surgeon Whipple to declare - “All in all, Susruta must be considered the greatest surgeon of the premedieval period.”18 Rhazes repeatedly quoted Sushruta as the foremost authority in surgery.13

The Sushruta's contribution in the field of Plastic Surgery can be enumerated as follows 2,5,10,11,14,17:

1. Rhinoplasty (cheek)
2. Classification of mutilated ear lobe defects and techniques for repair of torn ear lobes (15 different types of otoplasties)
3. Cheek flap for reconstruction of absent ear lobe.
4. Repair of accidental lip injuries and congenital cleft lip.
5. Piercing children's ear lobe with a needle or awl.
6. Use of suture materials of bark, tendon, hair and silk.
7. Needles of bronze or bone (circular, two finger-breadths wide and straight, triangular bodied, three finger - breadths wide)
8. Classification of burns into four degrees and explaining the effect of heat stroke, frostbite, and lightening injuries14.
9. Fourteen types of bandaging capable of covering almost all the regions of the body and different methods of dressings with various medicaments.
10. Use of wine to dull the pain of surgical incisions.
11. Described 20 varieties of sharp instruments *(sastra) and 101 types of blunt instruments (yantra) and their handling techniques.
12. Systematic dissection of cadavers.
13. Advocated the practice of mock operations on inanimate objects such as watermelons, clay plots and reeds.
14. Use of leeches to keep wounds free of blood clots.
15. A code of ethics for teachers as well as students.

*”should have an edge so fine that it should divide the hairs on the skin.”

The Sushruta's contributions to allied fields are: 2, 3, 5,10,11,14

1. Surgical demonstration of techniques of making incisions, probing, extraction of foreign bodies, alkali and thermal cauterization, tooth extraction, excisions, trocars for draining abscess draining hydrocele and ascitic fluid.
2. Described 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, accidental perforation of the abdomen with protrusion of omentum.
3. Classified details of the six types of dislocations, twelve varieties of fractures and classification of the bones and their reaction to the injuries.
4. Principles of fracture management, viz., traction, manipulation, appositions and stabilization including some measures of rehabilitation and fitting of prosthetics.
5. Classification of eye diseases (76) with signs, symptoms, prognosis, medical/surgical interventions and cataract surgery.
6. Description of method of stitching the intestines by using ant-heads as stitching material.
7. First to deal with embryology and sequential development of the structures of the fetus.
8. Dissection and study of anatomy of human body.
9. Introduction of wine to dull the pain of surgical incisions.
10. Enumeration of 1120 illnesses and recommended diagnosis by inspection, palpation and auscultation.

Sushruta took surgery in medieval India to admirable heights and that era was later regarded as The Golden Age of Surgery in ancient India .Because of his numerous seminal contributions to the science and art of surgery in India, he is regarded as the 'Father of Indian Surgery' and the 'Father of Indian Plastic Surgery'.

In “The source book of plastic surgery'‘, Frank McDowell aptly described Sushruta as follows19: “Through all of Sushruta's flowery language, incantations and irrelevancies, 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.”

References

1. Sushruta Samhita. English translation by Kaviraj Kunja Lal Bhishagratna,
Calcutta, 1907, Chapter 16, 152-154.
2. Bhishagratna KK. The Sushruta Samhita. [English translation based on
the original Sanskrit text.] Varanasi, India, 1963; Chowkhamba Sanskrit
Series Office.
3. Raju VK. Sushruta of ancient India. Indian J Ophthalmol 2003; 51:119-
122.
4. Rana RE, Arora BS. History of plastic surgery in India. Journal of
postgraduate Medicine 2002; 48:76-8.
5. Das S. Urology in ancient India. Indian J Urol 2007;23:2-5.
6. Wise TA. Commentary on the Hindu system of medicine. Thacker:
Calcutta; 1845:1.
7. Hoernle AF. Studies in the medicine of ancient India. Clarendon Press:
Oxford; 1907:109.
8. Johnston-Saint P. An outline of the history of medicine in India. Indian
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Shastra – surgical instruments of Ayurveda – Astang Hriday Sutrasthana 26

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Let us explore various sharg surgical instruments used in Ayurveda. This is the 26^th chapter of Ashtanga Hrudaya Sutrasthana, written by Acharya Vagbhata, son of Vaidyapathi Simhagupta. The chapter name Shastra Vidhi Adhyaya. Shastra means sharp surgical instrument. 

Shastras- sharp instruments are 26 in number.
Shastras should be prepared from skilled metal smiths, as per traditional method of preparing surgical instruments.
They should be generally six Angula (fingers breadth)- long, capable  of splitting the hair/shaving, good to look at, with sharp edges, good to hold firmly;
The Yantras should not be of ugly shape. They should be prepared from  well blown – removed of impurities strong steel like iron.
The front of their mouth. i.e – the shape edges well hammered – to make them sharp, having the color  of the blue lotus, with shape in accordance with their name, always ready at hand for use, their blades- cutting edges being 1/4^th, ½th or 1/8^th of their own size (total length).
Each – instrument two or three in number should be made use as suitable to the place site of operation. 1-4

Names of Shastras -
Mandalagra, Vriddhiptra, Uttpala Patra, Adhyardha Dhara, Sarpa Mukha, Eshani, Vetasa Patra, Sarari Mukha, Trikurchaka, Kushapatra, Atavadana Atimukhi, Antrarvaktra, Ardha chandraka, Vrihimukha, Kuthari,  Shalaka, Anguli Shastra, Badisa, Karapatra, Kartari, Nakha Shastra, Danta lekhanaka, Suchi, Koorcha, Khaja, the four kinds of Ara, and Karna vedhanaka- are the names of the twenty six sharp instruments.

Mandalagra Shastra- knife with round edge at its tip has its edge in the shape of nail of the index finger, to be made use of for scraping and cutting-excision, in diseases like Pothaki- cyst in the eyelid, Shundika- Tonsils etc. 5

Vridhipatra- Scalpel is shaped like a boarders knife- Razor, useful for cutting, excision, splitting, incision and tearing/ separating, it, with a straight edge, is for use in elevated – bulging swelling, the same with its tip bent backwards, long or short edge for use in deep seated swelling. 6

Utpalapatra and Ardha dhara- lancets are for the purpose of splitting and cutting. 7

Sarpyasya- Sarpamukha- serpent bladed scalpel is meant for cutting – excision of polyps in the nose and ears and has an edge of half Angula.

Eshani- sharp probe meant for exploring sinuses, is smooth and shaped like the mouth of an earthworm. 8

Another kind of Eshani- probe meant for splitting, has its blade like a needle, with a slit- hole at its root.

Vetasapatra is for puncturing;
Shararimukhi- shaped like a heron’s beak’s kind of scissors and
Trikuracaka – three spiked Brush like  instrument are meant  for draining out liquids. 9

Kushapatra- Razor resembling Blade of Kusha grass and
Atimukha- razor resembling the beak of a hawk are meant for draining,  edge is two Angula – in length.

Antramukha – is meant for draining, its edges – 1.5 Angula in length and Shaped like half moon. 10

Vrihimukha- with blade like a grain of rice,  its edge being one and half Angula- in length and meant for Puncturing veins and the Abdomen. 11

Kuthari – Axe is thick, Stout, resembling a cow’s tooth, with edge of half Angula- in length  and having a wooden handle; from this the vein situated on bones should be cut leeping the handle of this Axe vertically over it. 12

Shalaka – rod made of copper, with two edges on either side shaped like the bud of Kurabaka, meant for piercing the lens in Linganasa- Cataract couching. 13

 Anguli Shastra- finger knife is prepared so as to have an orifice.
Its  edges are sharp, with its half Angula in width, resembling either Vriddhipatra or Mandalagra, in shape, capable of permitting the entry of the first Phallange of the index finger, is tied to  the finger with thread and meant for excision and splitting of the diseases portion in diseases of the passage of the throat. 14-15

Badisha- sharp hook with a bent blade is meant for holding enlarged Uvula, Arma- Pterygium etc.

Karapatra- saw is meant for cutting of the bone, should have strong edge, of ten Angula- in length and width of two Angula, with fine- sharp, small teeth and with a handle to be held tight with the fist. 16

Kartari- scissors meant for cutting tendons, threads, hairs etc, is like scissors – which is commonly used by layman.

Makhasa– Has cured or straight, edge, two bladed- shaped edge on both sides, nine Angula in length, to be  made use for removing minute foreign bodies, excision, splitting and scraping. 18

Danta lekhanaka- dental lancet, has one edge four Angulas, Shaped like a knot on one side, is meant for scrapping the tartar on the teeth. 19

Soochi – needles for suturing/ swing is of three kinds; round, strong and sout; having – passing in through a hole in their body near its root; that for use in fleshy parts will have three edges and length of three Angula, for use in less flashy places, bony joints and wounds on joints, with a length of two Angula. 20

Vrihimukha Soochi- curved needle is bent like a bow, meant for use- sewing/ suturing of instesties, stomach and vital spots and two and half Angula in length. 21

Koorcha - brush with sharp spikes with round spikes fixed on one end, for seven or eight number and fastened well; it is used for scrapping in Nilika- blue patches, Vyangga- dark patches on the blade and loss of hair etc.22

Khaja- churner has blade of half Angula in  length and is of round shape, with eight spikes- fixed in it meant for removing the – vitiated blood from the nose by Churning with the  hands. 23

Karnapali Vyadhna- instrument for puncturing the ear lobe should have its blade in the shape of bud of Yuthika- Jasmine. 24

 Ara- Awl, cutting plate has a round blade of half Angula below and four blades- edges above, it should bee used for puncturing swellings in case of doubt whether it is ripe or urine, as also – the earlobe which is thick. In case of thick earlobe a needle, hollow in three parts of it, three Angula in length is best for puncturing. 25-26

Anu Shatra – Accessory instruments:-
Anushastras are -
Jalauka – Leeches,
Kshara – caustic Alkalies,
Dahana – fire,
Kacha – glass
upala –cow dung cake
nakha – nail
stone, nail etc, which are non-metallic.
Many other instruments may be designed as required for use in special operations and sites. 27

Shastra Karya – functions of sharp instruments-Utpatana- extracting,
Patana- tearing / splitting,
Seevana- Suturing,
Eshana- probing,
Lekhana- scraping,
Pracehhana- Scratching, incising, minute puncturing
Kuttana- beating, hitting, pounding
Chedana –  excising, cutting,
Bhedana- breaking,
Vyadhana- Puncturing,
Manthana- Churning,
Grahana- holding, grasping and
Dahana- burning, cauterizing  are the functions of sharp instruments.28

Shastra Dosha – defects of sharp instruments:-

Kuntha – Bluntness,
Khanda – brokenness,
Tanu- thinness,
Sthula – stoutness,
Hrsava – smallness,
Deergha – lengthiness,
Vakrata – curvedness, irregular shape
Kharadaratva – rough edge – are defects of sharp instruments.29

 Shastragahana Vidhi:- Method of holding sharp instruments:-

For Chedana (cutting), Bhedana (breaking) and Lekhana (scraping),  the instrument should be held in Vrunta phalantara- between round woods handle and the edge, with the help of index, middle fingers and the thumbs, carefully;
for Visravana (draining), it should be held at the tip of the round wooden handle with the help of the index finger and the thumb;
For Pracchanna (scorching, scratching), the tip of the handle should be held with the palm.
Vrihimukha Shastra should be held at is mouth tip;
for extracting, the instruments should be held at their root;
Others may be held in a convenient manner, as required in the operation. 30-32

 Shastra Kosha- instrument wallet:-The instrument wallet should be 9 Angula width, 12 Angula in length.
It should be made from jute, leaves, wood, silk, inner bark of trees or soft leather.
It should be endowed with threads, well stitched with compartment for instruments, which should be kept wrapped in wool;
Its mouth closed and held tight with a rod- acting like a bolt and pleasing to look at. 33-34

Jalauka- leeches-

Leeches are born in dirty water contaminated by putrifying dead bodies of fish, frog and snake or their excreta;
Indrayudha type of leeches -Red, white or very black in color;
Chapala – very active,
thick and slimy,

Poisonous Jalauka -Those which have
Chitra – varied lines on their back, and
Urdhvaraji – which are very hairy are Savisha- poisonous and so should be rejected.
If used, they produce itching, ulceration, fever and giddiness, these- ailments are to be treated with drugs which mitigate poison, pitta and blood. 35-36 ½

Nirvisha Jalauka – safe leeches -
Those born in clean water, which are blue, round in shape, having blue lines in their back, rough/ hard back, thin body, slightly yellowish belly are Nirvisha- non poisonous- so can be used. 37-38

Even these, when they do not vomit the sucked blood fully,  when  they are applied frequently, and when they are inactive even after getting into water, should be considered as blood intoxicated and should be rejected. 39

 Jalaukavacharana- procedure of applying leeches:-

The leech that are kept for short time in water containing paste of turmeric / grain washed water (Avantisoma)/ buttermilk should be made comfortable by putting back in pure water.
should be made to stick to the body of the patient.
The leeches are attracted to the desired part of the body, by rubbing the part with ghee, mud, breast milk / blood or by making a wound with a sharp instrument.
When it starts drinking blood by raising its shoulders, it should be covered with a soft cloth.

Thus stuck up, the leech will suck only the vitiated blood first from the mixture of vitiated and un-vitiated blood, just like the swan sucks the milk from a mixture of milk and water. 40-42

Application of Leeches mitigates diseases such as,
Gulma – Tumors of the abdomen
Arsha – Haemorrhoids,
Vidradhi – Abscess,
Kushta – skin diseases
Vatarakta – gout,
Galamaya,Netraruk – diseases of the neck and eyes,
Visha – poison,
Visarpa- herpes. Etc

When pricking pain or itching develops at the site of the bite, the leech should be removed; they are then made to vomit the sucked blood by touching their mouth with salt and oil or by gentle rubbing in the direction of their mouth after smearing fine rice flour over them. 43

After making them vomit they should be protected from blood intoxication and should not be used again for seven days.

After proper vomiting, the Leech regains its previous activity and becomes strong;
by too much of vomiting it becomes very weak or may even die;
If vomiting is improper, it becomes lazy, inactive and intoxicated. 44

They should be transferred from one pot to another, filled with good mud and water, in order to destroy- avoid putrefaction by saliva, excreta of leeches, because the Leeches become poisonous with such a contact. 45

अशुद्धौ स्रावयेत् दंशान् हरिद्रागुडमाक्षिकैः ॥४६॥

शतधौताज्यपिचवस्ततो लेपाश्च शीतलाः।

When in doubt of impurity, the site of the bite should be made to bleed by applying paste of Haridra (Turmeric), Guda (jaggery) and honey.
Later a piece of cloth soaked in Shata Dhauta Ghrita or cooling pastes prepared from drugs of cold potency should be applied – over the site.

With the removal of vitiated blood, the redness and pain subside immediately. 47

The vitiated blood, displaced from its site and accumulating in the interior of the wound becomes greatly sour by stagnating overnight; hence it should be expelled out again. 48

A gourd or pot (cupping method) should not be used to remove the vitiated blood when the blood is vitiated by pitta, for they are associated with fire. It would further aggravate Pitta. They should be used in case of vitiation by kapha and Vata imbalance. 49

The blood vitiated by Kapha should not be extracted by using a sucking horn (Shrunga)because of thickness of the blood, whereas blood vitiated by Vata and pitta should be removed by the sucking horn. 50

Shrunga is good for Vata and Pitta imbalance and not indicated in Kapha.

Ghata is good for Vata and Kapha but not for Pitta.

Pracchana – incising to produce bleeding:-

The part of the body  above the site, selected for bleeding should be tied tightly with a rope of leather scrap;
Tendons, joints, bones and vital spots are avoided and Prachanna karma (scratching, incision) by sharp scalpel  done from  below upwards.
It should not be done in horizontal direction.

Blood accumulated in any localized area- small area can be removed by Pracchana (scratching- incisions);
Blood accumulated in tumors, abscess can be removed by using leeches;
Blood that has produced loss of sensation- at the site of accumulation by using the sucking horn (shrunga) etc gourds or pot (Ghata) and
that which is soared all over the body by venesection. 55

Or removal of blood by incisions is done when the blood is solidified; by Leeches when it is deep seated; by gourd, pot or horn when it is localized  in the skin and by venesection when it is  pervading the entire body; by using horn, Leeches, gourd for the seats of Vata and others- Doshas respectively.54 ½

After the bleeding procedure, the site of bleeding should be covered with cooling paste.
This will reduce the pain, itching and oedeme at the site.
The area should  be bathed with warm ghee. 55

Thus ends the chapter- Shastra Vidhi- the 26^th  in Sutrathana in Astangahridaya.