Surgery in ancient India was highly developed. Even up to the 18th century, before the British came, plastic surgery was being practiced in India. Pattenshetty has given a detailed account of the knowledge of surgery in ancient India in the essay quoted above.
The present paper Surgery in Ancient India: Its Evolution and Progress, appearing in volume IV Part 2 named the Medicine and Life Sciences in India, has been contributed by N. K. Pattenshetty who specialized in Clinical and Research Methodology. Pattenshetty was engaged in Rural Medical Service in Karnataka and also taught Ayurveda at degree and post-graduate levels.
In the very introduction Pattenshetty tells us that Indian Surgery that forms one of the eight specialties of Ayurveda, was known as Salya-tantra in ancient texts and that Salya-tantra had along with the other seven specialties of Ayurveda had reached the zenith of achievement at an early stage of Indian history. Out of the four Vedas, the Rigveda, Yajurveda, Samveda and the Atharvaveda that are held sacred by the Indians, Ayurveda is said to have its origin in the Atharvaveda compiled sometime during 1000 BC, though Pattenshetty contemplates that knowledge of surgery in India must have been known many centuries before the Christ. Susruta, who authored the Susruta-tantra around 400 BC, is usually called the Father of Indian Surgery. He was the son of Visvamitra and a disciple of Kasiraja Divodasa Dhanvantari, a renowned surgeon simply known as Dhanvantari. Susruta's Susruta tantra is probably the earliest record on surgical procedures. Until the time of Susruta there was no systematic record of the treatment procedures, yet Pattenshetty believes that surgery as treatment of wounds must have been known in India centuries even before him. The paper tells us that Susruta systematized the scattered knowledge of the various aspects of surgical techniques and also of allied subjects like obstetrics, gynecology, pediatrics, geriatrics and ophthalmology, including a description of anatomy, physiology and pharmacology thus making the Susruta-tantra one of the most comprehensive compendia of his times. Pattenshetty tells us that the Susruta-tantra is lost to posterity but its redacted version by Nagarjuna (5th century AD) is now available by the name Susruta-Samhita.
Since the Susruta-Samhita is the earliest extant record of surgical knowledge in India based on the Susruta-tantra, Pattenshetty in this paper describes the contents of this Samhita. The Samhita has been divided into six sthanas or six volumes, dealing with different aspects of surgery. It is so comprehensive as to include the fundamental concepts of surgery, knowledge about herbs and drugs, diagnostic aspects of different diseases, physiological and embryological aspects, therapeutics, poisons and science of nutrition. It is surprising to find extensive treatment of subjects like Pediatrics, Ophthalmology, Geriatrics, reproduction and virility, and social hygiene in this Samhita. It might make us wonder that in this Samhita a whole volume is devoted to the study and treatment of ailments through Psychotherapy as well, which has been accorded recognition and happens to be a rapidly growing science in the modern world. Pattenshetty says that in any case, going through the Susruta Samhita available now in its redacted form, we can observe that every subject is classified and explained in a scientific manner, in the form of groups and sub-groups, divisions and sub-divisions. He further says, such classifications were possible because of wide practical experience, close observation and logical interpretations.
Though Pattenshetty in his description does not use the same pattern of division according to the volumes enumerated in the Susruta Samhita, yet there is a certain similarity in the two.
The Samhita in its first sthana or volume enumerates the fundamental concepts of Salya-tantra or Surgery, which Pattenshetty has divided into eight sections:
1) Vrana and Vranasopha which this paper describes as Wounds and Inflammation. After the identification of wounds and inflammation separately, the Samhita describes sixty types of management 'Sasti Upkrama' of these. The subject of inflammation, ulcer and wound, their process of repair and management occupy relatively greater space in the Samhita.
2) Dagdha-Vranas or Burns and Scalds. Accidental burns are grouped into four categories depending upon the tissues burnt, which are described as partial epidermal first degree burns, dermo-epidermal second degree burns, whole skin thickness third degree burns and fatty and muscle layer fourth, fifth and sixth degree burns. It is recognized that special kinds of burns such as asphyxiation by hot fumes, sun stroke, frost-bite and chilblain, burn by extremely hot objects and burn by lightning required specialized treatment.
3) Sonita sthapanam or Haemostasis is bleeding wounds. The Samhita divides the detailed procedures of controlling hemorrhage into four groups as Sandhanam approximation of wounds, Skandanam use of coagulants, Pacanam or cauterization by using caustic drugs and Dahanam cauterization by use of hot objects. Pattenshetty tells us that each one of the above measures is more potent than the previous one and is indicated one after the other to bring about homeostasis.
4) The next section in this first volume is devoted to Bhagna fractures and dislocations. Here Susruta necessarily had to describe the types of bones found in the body. Pattenshetty says that today we are able to examine an injured bone directly under radiological examination but in the absence of this Susruta had evolved this useful and most logical method of determining the types of fractures by inference. Susruta classified the skeletal injuries into two broad groups (1) sandhi bhagna or dislocation of joints and (2) asthi bhanga or fractures. Under this section Susruta also discusses the management of skeletal injuries through traction, manipulation by pressure, by reduction or apposition and immobilization. Mention of the management of compound fractures, physiotherapy and use of splints is also found in this Samhita. Susruta had also identified the barks and wood of various trees that were found to be useful to serve as splints. Pattenshetty says that what Susruta suggested several centuries ago with meager facilities of carrying out clinical investigations is so perfect that there is hardly any room to permit any alteration at present. The principles laid down by him indicate the height of development of Indian Surgery during that remote period.
5) Karna-nasa-ostha Sandhanam or the Ear, Nose and Lip reconstructive surgery. It is most surprising here to find the mention of Plastic Surgery by Susruta who described fifteen varieties of repairing torn or defective earlobes. Pattenshetty says Susruta may be called the father of Plastic Surgery. In addition, Rhinoplasty or Nasa-Sandhanam and Ostha-Sandhanam or labioplasty have also been elaborately described by Susruta which are his outstanding contributions. Till the 19th century this branch of surgery had made little advance anywhere in Western Countries.
6) Anusastra Karma or Para-Surgery. In para surgery as a specialty Susruta has advocated the use of Ksara medicinal caustics and agni thermo cauterization. Pattenshetty says there is no cure for these in modern surgery. He says except for a few varieties of bhagandara fistula in ano- and arsus haemorhoids where surgery was indicated a majority of these ano-rectal conditions were subjected to para-surgery.
7) Rakta Visarvanam or Rakta Moksanam that is Blood letting. Susruta seems to have been of the opinion that the onset of a number of diseases could be prevented by following a proper method of blood letting. He advocated five types of different methods to let out the vitiated blood. 1. Siravyadha-vene puncture by certain surgical instruments, 2. Visana by applying horn, 3. Tumbi application of bitter gourd, 4. Jalauka the application of leeches, and 5. Pada or pracchana incising by a surgical instrument. In this section a detailed description of the surgical instruments and accessories used for the surgical procedures described later in the paper is given, which can make even the most distinguished of surgeon's wonder at the ingenuity of the ancient Indian surgeons. Pattenshetty also gives the diagrammatic representation of these and also describes the medicaments and types of bandages utilized by Susruta.
Here Pattenshetty does not use the name Nidana Sthana for his next heading as accorded to the second sthana by Susruta and Nagarjuna and names it as Diagnostic methods. The second volume of the Susruta Samhita deals in the diagnostic methods as well. Pattenshetty says that Susruta's method of diagnosing a surgical or medical disease though connected with the humoral theory in general was not restricted to mere speculations. He has given explicit instructions regarding the History-taking and the physical-examination patients. The physical examination of a patient includes the use of all the five senses on the part of the physician which is basically the same as the method used these days.
The third broad heading that Pattenshetty uses is Surgical Training that is quite similar to the third volume the Sarira Sthana of the Samhita that deals in the anatomical, physiological and embryological aspects including pre- and post-natal care of the mother and child. It deals in knowing the body better and so perhaps rightly named by Pattenshetty as Surgical Training. Pattenshetty tells us that Susruta happened to be the first surgeon to evolve a sound method of training for his students in surgical skills. He stressed the importance of observation and practical experience in the art of surgery. Further, Pattenshetty says that Susruta might also have been the first person to advocate dissection of the human body to gain first hand knowledge of human anatomy. It has been perhaps rightly pointed out by Pattenshetty that the historians of the western science attribute the evolution of modern rational medicine to Hippocrates and marginalize the contributions made by Susruta. Susruta has described the dissection of the human body and given a vivid description of all the anatomical parts like skin, membranes, groups of viscera, vital structural and functional components, arterioles, venules, lymphs and nerves, muscles, ligaments, tendons, bones, joints and vital points, metabolic byproducts, external orifices and respective passages, network of plexuses etc. Pattenshetty says that before a student of surgery was granted permission to practice on human beings he was required to attain a sufficient amount of skill in various surgical procedures by constant practice on ingeniously devised experimental models.
Finally, Pattenshetty exposes the surgical procedure as practiced in the days of Susruta. We are told that each surgical procedure was a phased programme Trividha Karma of three parts. The first was of the Pre-operative measures (Purva Karma), second the Operative measures (Pradhan Karmas) and the third was of the Post-operative measures the Pascat Karma. Here Susruta in addition to emphasis upon the surgical procedure describes certain procedures to bring the body to as ideal a state of health as possible. These include restriction of diet, local application of medicated pigments, local irrigation by liquids, softening by anointing, sudation or fomentation, resolution, letting out blood, internal administration of medicated oils, ghee etc, emesis, purgation and poultices for preventing suppuration etc. Susruta insists that the patients who opt for elective surgery the above procedures if adopted judiciously may curtail or prevent the likely complications that may arise during or after the surgery. As regards the preparation of the surgical instruments for operation they have to be thoroughly cleaned, sterilized and kept ready for use. The operation is to be conducted in a separate Agara Operation Theatre, which should be free from contamination, even by direct sunlight and air currents. Pattenshetty says that the principle involved in administering a suitable anesthesia to a patient in the pre-operative period is again Susruta's contribution.
Under the operative measures Susruta describes eight types of surgical procedures. They are Chedanam Excision, Bhedanam Incision, Lekhanam Scraping or curettage, Vyadhanam Puncturing, Visravanam Drainage, Esanam Probing, Aharanam Extraction by sharp hooks, and Sivanam Suturing.
Postoperative measures as described by Susruta include all the measures that should be taken up after the completion of a surgical procedure till the patient is completely cured of the disease. He insists that a careful and minute follow up regarding appropriate bandaging, antiseptic fumigation, dietetics and rest, should be undertaken as post operative measures. Further, Susruta also recognized that infection could spread from person to person through close contact, sexual intercourse, inhalation, ingestion and also by the use of infected objects. Hence, he advised that these should be guarded against in the patient during the postoperative period of the patient.
Pattenshetty's paper is an eye opener for all, who influenced by heresy and the Eurocentric views as regards the history of science and knowledge suspect the advances made by India in the yore. Modern medical knowledge with its superior instruments could greatly benefit from the simplicity of the inferences drawn and the procedures employed in the medical knowledge contained in the Susruta Samhita. It is time that the history of science and technology accorded due recognition to the knowledge of the past, as its bases may be as good in reason, logic, objectivity and inference as the modern Western knowledge.