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History of Technology in India, Vol. I: From Antiquity to c. 1200 A.D. v1.c21: 4.4 Surgical Techniques

History of Technology in India, Vol. I: From Antiquity to c. 1200 A.D. v1.c21

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English

Contents

4.4 Surgical Techniques

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Hindus believe the existence of Indian Medicine to be of divine origin. Lord Brahmā, the first member of god triad (*Trideva*), was the profounder of Ayurveda, the science of life. There is vivid description of Ayurveda in *Ṛgveda* and *Atharvaveda*. Divodās Dhanvantari was the direct disciple of Indra and he preached his scientific knowledge pertaining to surgery to his disciples, particularly addressed to Suśruta. In classical age, ancient surgery was considered the most important and significant branch of Ayurveda. In the mythical of Ayurveda itself, ancient surgery was accorded the first place and headed amongst the eight divisions of Ayurveda.

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The vast medical literature of ancient India practically remains as yet unexplained, and any undertaking, which has the object of making that terra incognita, known to the scientific world, is bound to be welcomed by the public. The west, until the close of the eighteenth century, remained ignorant of the achievements of the ancient Hindus in art, science and culture.

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The treatise of *Caraka* and *Suśruta*, as revised and redacted by the later Hindu philosopher - physicians of the Ayurveda, was entitled to a great respect, and was associated with the *Atharva Veda* in a special way. The work of ‘Suśruta’ is one of the greatest of its kind in Sanskrit literature.

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It is especially important from the surgical point of view and to him to be contributed the glory of first changing the art of surgery into a practical science, during the Vedic Period. It seems that from time to time many hands were in operation or what passes on as the *Suśruta Saṃhitā* today and the available evidence points out that the original treatise of Vṛddha Suśruta, the *Suśruta Tantra*, was a different work and formed the basis of the Saṃhitā, which was probably entirely revised, at a later date, by another author, also called ‘Suśruta’ by name, and again enlarged and supplemented by Nāgārjuna in the second century B.C. The original Tantra, according to A.F.R. Hoernle (1907), indeed admittedly belongs to a much earlier period, possibly as early as about 1000 B.C. Hessler (1844) who edited Suśruta Saṃhitā in Latin language, also places Suśruta during the heroic age of India, though the beginning is not known but the end of which is marked by the 1,000 years B.C. The other European scholars like Lietard (1863), Dymock (1870), and Max Neuberger (1901) have mentioned various dates to Suśruta, ranging from the first century A.D. to the tenth century A.D. Considering all the evidence available today, one comes to the conclusion that, the “lower limit of Suśruta’s death is fixed” as the sixth and seventh century B.C. This being the date of Śatapatha Brāhmaṇa, while practically nothing can be said about the upper limit (Das Gupta, 1932).

Definition and importance of Śalya (ancient surgery)

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Śalya is the name applied to the art of surgery in Indian Medicine and is derived from the root Śal or Śval meaning to move quickly. Foreign bodies of every kind are denoted as Śalya, but it specifically refers to the arrow, which was the commonest and most dangerous foreign body causing wounds and requiring surgical treatment during the Aryan invaders, and surgeons were directly requisitioned to attend on the wounded.

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The Śalya Tantra or the science of surgery is the oldest of all the other branches of the science of Indian Medicine (Ayurveda) and is further corroborated by the four classes of testimonies, i.e. perception, inference, analogy and scriptural truths. The primary position of ancient surgery may be inferred from the fact that surgery lands her aid materially towards the healing up of traumatic ulcers. Moreover, Indian surgery (Śalya Tantra) is considered to be the most important as instantaneous actions can be obtained with the help of surgical operations, external applications of caustics, cauterisation, blood-letting, etc. Secondly, it contains all that can be found in the other branches of the medicines as well. It is eternal and is source of infinite piety, imparts fame and opens the gates of Heaven to its voteries, prolongs the duration of human existence on earth and helps the human beings in successfully fulfilling their missions and earning a decent competence in life.

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It has always been a matter of speculation how the ancient surgeons ever performed the major surgical operations successfully in the absence of anaesthesia, haemostatics, antiseptics and antibiotics.

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However, the knowledge of anatomy was requisite to them as evidenced by the concept of marmas (vital points) based on regional anatomy. The ancient surgeons were quite aware of the infections following surgical operations and they extended top priority to prevent it.

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The clinical approach and major surgical operations i.e. peptic ulcers, perforations and paracentasis, etc. mentioned by Suśruta, the father of Indian Surgery have opened a new avenue to modern surgery. The scientific approach to perform rhinoplasty as well as otoplasty pertaining to plastic surgery in 6th century B.C. had been appreciated by the modern surgeons. Herschberg of Germany mentions that “Our entire knowledge of plastic surgery took a new turn when those cunning devices of India war became known to us.”

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Thus, in *Rgveda*, we read of the amputations of legs and fitting with artificial limbs, extraction of arrow from the limbs of the wounded, and enucleation of eye and corneal grafting with great success.

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The most outstanding performances of Indian surgery, however, were on a domain of transplantation of organs, plastic surgery, urolithotomy and laparatomy, etc. Divodās Dhanvantari recites an incident which took place in one of the wars of the gods. Rūdra chopped off the head of the Yagna, then on the request of the gods the Aśvinī brothers (twin) undoubtedly reimplanted the head of the Yagna to the trunk successfully and restored him in life.

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In another instance, the head of Dadhicī was cut off and the head of the horse was transplanted to him. Later on, the original head of Dadhicī was reimplanted to him after removing the head of the horse. It is an excellent example of heterotransplantation. It clearly indicates that the transplantation surgery was highly developed and practised in ancient India. There are several other instances where severed parts of the human beings were transplanted with success.

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Once, the wife of king Khela named Vispala had lost one of her legs in the war. The Aśvinī brothers provided her with a metal leg (artificial limb). The father of Rijashva became blind as a result of cursing, and the corneal grafting was successfully carried out to restore his normal vision. The broken teeth of Puśan were restored as normal. Moreover, the Aśvinī brothers demolished all the diseases of the gods and gave them young life. Suśruta was one of the matured and most knowledgeable pupils amongst other several disciples of Divodās Dhanvantari. Therefore, he imparted his scientific knowledge to Suśruta. Moreover, the training of surgeons, meticulous code of personal ethics, and the social conduct for the medical profession in general, have touched the highlight of Suśruta’s contribution. These are some of the topics which are not generally included in the modern surgery, and hence it would be of interest to the surgeons to know more about these important matters for improving their services to the humanity as a whole.

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It is generally accepted that Suśruta’s lucid and systematic presentation of the conceptual and technical aspects of surgery, as well as the philosophy and ethics of medicine was quite advanced and may have relevance even to-day (Thorwald).

Surgical Armamentarium of Susruta

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Status of surgery of any period can be best evaluated by variety and quality of the surgeon’s armamentarium. Suśruta has mentioned 101 blunt and 20 sharp instruments which could be the precursors of modern surgical instruments. Virtually, number of them have similar names such as *singhmukha yantra* (lion forcep), *mudrika sastra* (finger knife), etc. Varieties of needles (straight, curved or round body, blunt and cutting), suture materials, splints and fracture bed for immobilization of fractures at various sites, fourteen different types of bandages and parasurgical measures, i.e. cautery, etc. for checking the bleeding are further examples.

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Moreover, Suśruta has further mentioned the specific use of some instruments needed for the specific surgical manoeuver, such as endoscopy to visualise the haemorrhoids and fistula-in-ano and *mudrikā śāstra* (finger knife) for conducting blind surgical procedures in the case of retropharyngeal abscess or removal of the dead foetus through vagina.

Surgical Concepts of Suśruta Saṃhitā

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Suśruta has scientifically classified in a systematic way the clinical material and the fundamentals of management which are valid even today. Classification of traumatic wounds their prognostic evaluation as well as management, suturing in clean wounds, avoidance of sepsis, and careful suturing of intestinal perforation etc. are highly remarkable. However, he was the first to recognise the basic pathology of thermogenic injuries hot or cold.

Clinical Surgery by Suśruta

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The clinical approach and surgical treatment of certain abdominal disorders mentioned by Suśruta have given a new light to modern surgery. The management and surgical treatment of perforation of intestines mentioned by Suśruta in such an excellent way that it is being followed by the modern surgery, as well as the description pertaining to intake of blood seemed to be rational and scientific. In addition, Suśruta has given a clear description on paracentasis of abdomen in cases of ascites. After the complete outflow of the fluid, the abdomen should be firmly tied with a many tailed bandage in order to prevent further accumulation of fluid. In modern surgery too, the same surgical approach has been described, which affirms the value of the ancient surgery. The ancient method of surgical approach to remove the urinary calculi appears to be in no way different as worked out at the present era by the modern surgeons.

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Moreover, Suśruta has described various means of exiting the blood to cure a number of diseases. Thus, cupping, application of leeches, blood-letting in various forms were wide spread methods of treatment in many major diseases, i.e. high blood pressure, sciatica, and several other nervous ailments. It was most common during the ancient era and more than fifty percent of the diseases of the human being were cured by venesection(Sirā Vedha) or blood letting.¹

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Major surgical operations were carried out during the period of Suśruta, without anaesthesia. The most infrequent successful outcome of such operations, done regardless of all antiseptic precautions, could only be explained by the supposition that the aboriginal races had a greater power of resistance against wound infection than highly civilised nations. Moreover, the fumigation of operation theatre by guggulu and other similar indigenous drugs have been mentioned by Suśruta to prevent the infection in surgical cases. However, the modern surgery follows the same pattern of distempering the operation theatres these days. Surgical operations used to be performed on an auspicious lunar, day, star and movement after worshipping the god of fire, Brāhmins, physicians, with curdled milk, rice, drinks and jewels and after offering presents as well as blessings. Suśruta mentions three stages in the treatment of surgical diseases, i.e. the preliminary measures (pūrva-karma), the principal/surgical performance (pradhāna-karma), and the post-operative management (paścāta-karma). Great emphasis is being laid on the post- operative measures, caustic was considered superior to all cutting instruments. Fire (Agni) as well as cauterisation (Agnikarma) was regarded even more efficacious than the caustics. It was mostly used to erradicate the tumours, fistulae, elephantasis and haemorrhoids, etc.

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Similarly, the use of alkalies prepared in three strength, weak, medium and strong, was practiced for external and internal applications. External application was advised in all sorts of skin ailments, haemorrhoids, fistula-in-ano and other fistulae as well; internally they were used for poison of lingering effect, swelling of the body, loss of appetite, calculi and internal abscesses etc. At present, they are vastly used by followers of Suśruta in the form of ‘Kṣāra-sūtra’ (alkali braided thread) for the treatment of fistula-in-ano cases with excellent results. Moreover, the recurrence of the disease following the use of Kṣāra-sūtra is very minimal.

Splints

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The barks of several latex trees, i.e. madhuka, udumbara, aśvattha, palāśa, kakubhā, ban.boo, sarjā and banyan were used for the purpose of splints. It used to solve double purpose, the first as an antiseptic in cases of compound fractures and second, the soothing affect alongwith immobilization of the part.

Plastering

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A moderately firm bandage has been advised for optimum immobilization following the local application of certain indigenous medicines, i.e. manjiṣṭha, madhuka, red sandal wood and śali grain (rice variety) powder mixed with a hundred times washed clarified butter (ghṛta). This application of plaster helps to promote the union of fracture ends of the limb as well as combates the infection. Moreover, four methods of fracture reduction have been mentioned, traction, pressure, aposition and bandaging.

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Specific management of subungual haematoma, fracture of the toes, and fingers, bones of the hands and feet, humerus, femur, ankle, wrist, pelvis, ribs, naval bones, and skull fracture have been described. The fracture bed (Kapāṭa-Sayan) has also been advised in the case of the fracture of the neck of the femur for complete immobilization of the part, which is considered the unique contribution of Susruta as appreciated by the modern surgeons. Similarly the specific management of the dislocations of the hip, shoulder, the elbow, knee, ankle and wrist, the neck and the jaw have been described in a scientific way.

Methods of treatment for piles and fistula-in-ano

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There are four methods of treatment for piles. They are medicinal treatment, caustics, fire or cautery and surgery. Out of them, the piles which have a narrow pedicle, are projecting and moist should be treated by surgery. The soft, extensive, deeply situated and projecting ones are curable by caustic treatments while rough, firm, thick and hard ones are curable by fire cautery.

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Technique

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*Surgical operation* - A large pile mass having a narrow pedicle, moist and projecting, should be treated by surgery.

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*Pre-operative* - The patient suffering from piles should be oleated and sudated. He should then be made to sit in a covered and clear place in modern climatic condition, on a clear sky day and on a flat plank or on a bed. The anus should face towards the sun with the patient in the supine position, and the upper part of his body held in someone else’s lap.

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The waist should be raised a little higher. The neck and the legs should be fixed firmly by a strap and held firmly by assistants. Thereafter, his anus should be lubricated with *ghṛta* (clarified butter) and a sterilized well lubricated rectal speculum should be introduced in the rectum along its passage slowly while the patient is straining.

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Thus, the piles should be visualised and examined properly by the surgeon and the projecting pile mass should be clipped off with a knife and cauterized with fire to prevent bleeding. Thereafter, the pile mass should be mollified by the application of *ghṛta* mixed with *madhuka* and the instrument should then be taken out.

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*Post-operative* - Following the surgical operation, the patient should be made to get up and sit in warm water, whereas cold water should be sprinkled over him. He should then be taken into a room for post operative care with proper instructions.

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Technique of caustic application (Kṣāra)

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Following the pre-operative procedure as mentioned earlier adopted in the surgical operation, the pile mass should be pressed by a probe, wiped with a piece of cotton swab or a piece of cloth, caustic (Kṣāra) should be applied on it. Following this application of caustic, the opening of the instrument should be covered by the hand of the surgeon and should let it remain until the counting of one hundred (approximately one minute). Then after wiping, the caustic may be applied again, taking into consideration the strength of caustic as well as the severity of the disease. The application of the caustic should be stopped when the piles show the color of a ripe *jambu* fruit (Bluish black) and get depressed and shrivelled. Thereafter, the caustic should be washed away by sour gruel, curd, butter milk, vinegar or by the juice of citrous fruits. Then the pile mass should be mollified by the application of *ghṛta* or any medicated soothing oil and the instrument should then be taken out.

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The post-operative management of the patient should be maintained as described earlier. The remaining pile masses may be treated one by one at intervals of a week each. In case of multiple piles the right one should be handled first; after the right, the left one and after the left the posterior one; lastly the anterior one should be treated in the same fashion. The post- operative management and the dietary regimen should be according to the instructions mentioned by Suśruta.

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Fistula-in-ano (Bhagandara)

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*Surgical technique (General)*: The patient should be soothed by the application of medicated oil and his body should be fomented by immersing him in a receptacle of warm water. He should be put on a bed, positioned as described for the treatment of piles. The surgeon should examine closely as to where the mouth of the fistula is directed, outward or inward. Then a probe should be introduced carefully while the patient is straining and the fistulous opening located, raised on a probe, and cut by the knife; or else fire cautery or caustics should be used after proper assessment. This is the general surgical treatment for all types of fistulae.

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*Specific Treatment (Surgical)*: In cases of the *Śataponaka* type of fistula, the surgeon should connect one fistulous track with another by incising the tissues in between. External fistulae interconnected with one another should be excised separately (not all together). Thus, in a case of *Śataponaka* fistula (fistula having multiple openings), the wound should not be opened wide.

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*Types of Incisions for Śataponaka Fistula*: In a case of aforesaid fistula, the wise surgeon should make *Laṅgalaka* (Plough or T-shaped), *Ardha-laṅgalaka* (T or T like), *Sarvatobhadra* (circular), or *Gotirthaka* (semicircular) types of incisions.

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An incision equal to both sides is known ‘*Laṅgalaka*’; while an incision with one short arm is called *Ardhalangalaka*. An incision encircling the anus except the perineal raphe is known as *Sarvatobhadraka*. An incision made by introducing the knife from one side called ‘*Gotirthaka*’.

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All discharging passages should be cauterized by the fire cautery by the surgeon. The *Śataponaka* type of fistula is difficult to treat in the delicate and the timid.

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Post-operative management should be carried out precisely mentioned by Susruta in each type of fistula accordingly. There are five types of fistulae and each of them has its specific management which should be referred to the Suśruta Samhita.

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*Kṣāra-Sūtra* (thread prepared by alkalies): The application of *Kṣāra-sūtra* in cases of fistula-in-ano has commanded wide reputation and W.H.O. has extended recognition to it, considering its supremacy as well as the most simple technique. The chances of recurrences are rare. The patient can carry on his usual duties following the application of this medicated thread without any problem.

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Preparation of alkali thread or *Kṣāra-sūtra* - Surgical linen thread size 20 may generally be used for this purpose. This thread is impregnated into the lotion of (*haridrā*) turmeric. Then the latex of *Snuhi* is being applied on the thread and number of coating be done to enhance the activity of the thread. It should be used as fresh prepared or it can be stored carefully keeping away from the moisture. The alkali thread prepared from *Apamārga* and *Ark* may also be used.

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*Technique* - This prepared thread should be used through a specifically designed smooth, curved needle from the external opening of the fistula and should be taken out through the internal opening of the fistulous track. The surgeon should guard the needle putting his finger in the rectum to protect the rupture of the rectal wall. Then the thread should be knotted moderately and the dressing with *ghṛta* or medicated oil be done. The thread should be changed weekly till the fistulous track is completely excised. This technique is universally appreciated and adopted. This Kṣāra-sūtra is being made available in the market in the sealed tubes.

Management of the urinary calculi

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If the urinary calculi are not amenable to the medicinal treatment as described by Suśruta, surgery has to be the ultimate goal. The success is even uncertain in the hands of the expert surgeons, operation should be considered last of all in these cases and it should be carried out by a skilled surgeon, after taking the consent of the authorities concerned.

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Pre-operative preparation

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The patient should be oleated, his system should be cleansed with emetics and purgatives and be slightly reduced thereby. He should be massaged with oil, sudated, and be made to partake of a meal. Prayers, offerings and prophylactic charms should be offered and the instruments as well as surgical accessories, needed in the case should be arranged in proper order according to the instructions mentioned in the Sūtra-sthānam of Suśruta Saṃhitā Chapter V and he should be reassured.

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Position of the patient

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The patient of strong physique and unagitated mind should then be made to lie on his back on the table placing the upper part of his body in the attendant's lap, with his waist resting on an elevated cloth cushion and his knees as well as ankles fixed and tied together by straps.

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Manipulation of the Stone

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The umbilical region (abdomen) of the patient should be well rubbed with oil or with clarified butter (ghṛta), pressure should be applied by a fist below the navel until the stone comes down within the reach of the operator. The surgeon should then introduce into the rectum, the second and third fingers of his left hand duly anointed and with the nails well pared. Then the fingers should be carried upward towards the perineal raphe i.e. in the middle line, so as to bring the stone between the rectum and the penis, when it should be so firmly and strongly pressed as to look like an elevated tumour, keeping the bladder tense and distended so as to obliterate the folds.

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Contra-indications to surgery

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An operation should not be proceeded with, nor an attempt be made to extract the stone in a case where the patient would be found to drop down motionless (faint), with his head bent down, and eyes fixed in a vacant stare like that of a dead man, as an extraction in such a case is sure to be followed by death.

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The operation should only be continued in the absence of such an occurence.

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Operative Procedure and Technique (Perineal cysto-lithotomy)

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An incision should then be made on the left side of the perineal raphe at the distance of a barley-corn and of a sufficient width to allow the free egress of the stone. Several authorities recommend the incision to be on the right side of the raphe of the perineum for the convenience of the operation. Precautions should be taken so that the stone does not get broken, or crushed. Even if a small particle is left behind it again increases in size: hence, all of it should be removed by the curved forcep.

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In females, the uterus is adjacent to the urinary bladder, the incision should be directed oblique and upwards; otherwise a urinary fistula might result from the deep incision in that locality. Any hurt to the urethra during the operation would be attended with the same result even in a male patient.

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Post-operative management

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After removal of the stone the patient should be put in a tub of warm water and sudated. Thus the bladder does not get filled with blood, however, if it does get filled up, it should be irrigated through a catheter using the decoction of the latex trees.

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For the clearance of the urinary passage after operation, a treacle solution should be given to the patient; and after taking him out of the tub, the incidental ulcer should be lubricated with honey and clarified butter (ghṛta), the patient should be given warm gruel processed with urine purifying substances and mixed with ghṛta twice daily for three days. After three days, milk and treacle and small quantities of well cooked rice should be given for ten consecutive days. Thereafter, citrous fruits and juices prepared from wild animal's meat should be given. After that, for ten days he should carefully be given sudation therapy either by oils or by liquids. Then his wound should be washed by the decoction of latex trees. The medicated pastes of some indigenous drugs should be applied to the wound. A medicated oil or ghṛta cooked with turmeric and other indigenous drugs should be applied to the ulcer.

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Treatment of Impacted Urethral Stones

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It seminal concretions or gravels spontaneously coming into the urinary passage get impacted there, they should be removed through the natural passage. If this does not seem possible, the passage should be laid open and the concretions should be extracted by budish instrument (a hook).

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After the wound has healed, the patient should neither indulge in sexual intercourse, nor ride on a horse, an elephant, a chariot, or climb a mountain or a tree, for the period of one year; neither should he swim in water nor take heavy meals.

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Precautions

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The urinary passages, seminal passages, testicular-channels, trigone of the bladder (*Mūtrapraśeka*), perineal raphe, vagina, rectum and urinary bladder should be avoided from injury. If urinary passages are injured death occurs due to the bladder becoming full of urine. If seminal passages are injured death or impotency occurs. If testicular channels are injured loss of erection takes place. Injury to the vagina and the perineal raphe gives rise to severe pain. The features of injury to the urinary bladder as well as the rectum have been mentioned earlier.

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Suśruta should also be credited to be the first who described the removal of the stone from the bladder through the perineal route, a method which was still in extensive practice, till the last century. Celsus in 3rd century A.D. described it, but Indians have been practising this method for centuries earlier and it is possible. Celsus may have borrowed it from Indian sources although he has not mentioned it. Suśruta is precise and explicit in describing the operative procedure, the precautions to be taken, complications encountered and the post-operative instructions, etc. which indicate his thoroughness with the technique.

Intestinal obstruction and perforation of Intestines

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Laparotomy

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*Technique* - Cases of intestinal obstruction and of intestinal perforation should be oleated, fomented and anointed and then their abdomen should be incised below the navel, four fingers beyond the hairy line (midline) on the left side, and after bringing out the intestines four fingers in length at a time, they should be inspected carefully and the stones, hair balls or faecoliths obstructing the intestines in the intestinal obstruction should be removed. After applying the honey and *ghṛta* (clarified butter) the intestines should then be put back in their original position and the external abdominal wound should be sutured in routine way.

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Similarly, in cases of perforation of the intestines, after removing the foreign body and cleansing the intestinal discharges, the edges of the hole in the intestine having been brought together should be got bitten by black ants. When the ants have bitten the intestines their body should be chopped off and removed having the heads behind. Then the suturing should be done as before and other reparative measures should also be taken as described earlier. Black clay mixed with *madhuka* should then be pasted and bandaging completed. Thereafter, the surgeon should cause the patient to be removed to a chamber protected from draught and post-operative instructions should be issued. The patient should be made to sit in a vessel full of oil or *ghṛta* and his diet should consist only of milk.

Management of Ascites

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*Paracentasis* : A patient afflicted with ascites (*Jalodara*) should be first anointed with medicated oils, possessed of *vāyu*-subduing virtues and fomented with warm water. He should be made to stand and held firmly in the armpits by dependable persons attending on him. The surgeon should make a puncture with a surgical instrument known as the trocar (*Vṛhi-mukha*), on the left side of the abdomen below the umbilicus, to the breadth of the thumb in depth and at a distance of four fingers to the left of the dividing line of hairs (midline) in the abdomen. Simultaneously, with that a metal tube or a bird's quill, open at both ends, should be introduced through the passage of the puncture to allow the morbific fluids accumulated in the abdomen, to ooze out. And then having removed the tube or the Quill, the puncture should be lubricated with oil and salt and bandaged.

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The entire quantity of the morbific fluid should not be allowed to ooze out in a single day, inasmuch as thirst, fever, aching of the limbs, dysentery, dyspnoea and a burning of the feet might supervene in consequence, or as it might lead to a fresh accumulation of matter in the abdomen, in the event of the patient being of a weak constitution. Therefore, it should be gradually tapped at intervals of three, four, five, six, eight, ten, twelve, or of even sixteen days. After the complete outflow of the ascitic fluid, the abdomen should be firmly tied with a piece of flannel, silk-cloth or leather, so that gases may not cause distension.

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Diet - For six months the patient should take his food only with milk or with the soup of wild animals:

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The diet for the next three months should consist of (meals taken with) milk diluted (and boiled) with an equal quantity of water or with the meat soup of animals of the wild group seasoned with the juice of acid fruits. During the next three months it should consist of light and wholesome meals. This rule observed for a year brings about a cure.

Management of the Foetal malpresentation

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Craniotomy - In cases where there would be any necessity of using an instrument for the purpose of delivery, the enciente should be encouraged with hopes of life, before making the surgical operation. The head or skull of the child in such cases should be severed with the knife known as the circular knife (*maṇḍalāgra*) or the finger-knife (*Aṅguli-Sastra*). Then having carefully taken out the particles of the skull-bone, the foetus should be drawn out by pulling it at its chest/axillae or at the shoulder with a forcep (*Śaṅku*) of hook type. In case where the head would not be punctured and smashed, the foetus should be drawn out by pulling it at the cheeks or the eye-sockets. The hands of the foetus should be severed from the body at the shoulders when they would be found to have been obstructed in the passage and then the foetus should be drawn out. The abdomen of a child in the womb should be pierced and the intestines drawn out, in event of the former being swollen into a flatulent distension like a leather bag (for holding water), as such a procedure would remove the stiffness of its limbs, and then it should be drawn out. The bones of the thighs should be first cut out and removed, where the foetus would be found to have adhered fast to the passage with its thighs.

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In short, whatever part of the foetus gets stuck up, the surgeon should excise it and deliver the foetus fully and protect the woman with all care. (Figs 1-20)

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(a) (b) (c) (d) (e)

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Fig. 1. Some sharp instruments mentioned in Suśruta. a. Kurapatra śastra, b. Kuśapatra Śastra, c. Sūcī Śastra (needles), d. Trikurcaka Śastra, e. Vetaspatra Śustra

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(a) (b) (c) (d) (e) (f)

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Fig. 2. Some blunt instruments described by Suśruta

Hydrocele (Mūtraja Vṛddhi)

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Technique - In a case of an enlargement of the scrotum due to the derangement of urine (Hydrocele), it should be first fomented and then a piece of cloth should be tightened round it. A puncture should be made in the bottom of the sac with trocar (Vṛhimukha instrument). Then a canula should be introduced into the Fig.3. Maṇḍalāgra; Fig.4. Karapatra (saw); Fig.5. Vṛddhipatra (scalpel); Fig.6. Nakha Śastra (Nail Parer)

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Fig. 7

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Fig. 8

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Fig. 9

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Fig. 10

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*Fig. 7. Mudrikā Śastra (Finger Knife); Fig. 8. Utpal Patra Śastra; Fig. 9. Kuthrikā (Lancet); Fig. 10. Vṛhimukha Śastra (Trocar)*

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Fig. 11

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Fig. 12

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Fig. 13

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*Fig. 11. Lintarmukha (Curved Bistury); Fig. 12. Trikurcaka (Brush); Fig. 13. Kuśapatra (Pagets Knife)*

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Fig.14. Atimukha; Fig.15. Sararimukha (Scissors)

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Fig.16. Diagrammatic Section of the anal canal showing the position of the anal fistulae : Blind Low, External Fistula; Complete Low, Anal Fistula.; Fig.17. Complete Low Fistula (With high blind)

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Fig.18. Kṣārasūtra (First day); Kṣārasūtra, (completed from external opening through internal opening)

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Fig.19. The technique of Raktamokhana (Venesection)

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Fig. 20. The Method of Spilintage of Fractured Bone by using bamboo.

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puncture and the accumulated (morbid) fluid should be let out. The canula should then be taken off and the scrotum should be tied up with the stump bandage. When it has become clean healing procedures should be employed.

Inguinal Hernia (Antra-Vṛddhi)

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*Technique* - The scrotal swelling due to the descent of the intestines should be avoided as irremediable. In a case of bubonocele the procedures indicated for pacifying vitiation of *Vāta* are beneficial. If the swelling is in the inguinal region fire cautery should be applied with a semilunar rod to obstruct the path. The complete hernias descending to the scrotum should be avoided. The skin of the thumb of the contralateral limb should be incised in the middle and cauterized with fire.

Plastic Surgery

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Rhinoplasty

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Manu mentioned ears and nose amongst the parts of the body on which punishments were to be executed. Cutting of the nose was the usual punishment for adultery. This gave ample opportunity to the ancient Indian surgeons for operation of otoplasty (repair of the ear lob) and rhinoplasty.

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*Technique* - The technique and method of repairing the nose which has been chopped off, has been described in excellent scientific way. The portion of the nose to be covered should be first measured with a leaf. A piece of skin flap of required size should then be dissected from the cheek or from the forehead and turned back to cover the nose. The part of the nose to be prepared well by making it raw and the surgeons should join the two parts quickly but evenly and calmly and keep the skin properly elevated by inserting two tubes inside the nostrils, so that the new nose may look comely. The flap of the skin taken from the cheek or forehead is being kept intact for having proper blood circulation in the repaired area.

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Suśruta has described these details in the most scientific way by quoting the verses in his treatise of *Suśruta Saṃhitā*, Sūtrasthānam, Chapter XVI.

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Similarly, the Otoplasty as well as the repair of hare lip has been mentioned by Suśruta, the father of Indian Surgery in 6th Century B.C. (Fig. 21)

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Fig.21. The technique of removal of skin flap for doing the Rhinoplasty

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Fig.22. Suśruta's method of Plastic Surgery : Nemisandhanaka, Gamdakarṇa, Ear-Plasty and Lip- Plasty

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It is well documented historical fact that the impetus to modern plastic surgery was provided by the reporting of Rhinoplasty through a forehead flap conducted by itinerant Indian Surgeons in ‘Gentle men's Magazine’ of London in 1794. Simplicity and success of the procedure was proved by Carpue in 1814 with minor modifications is still one of the standard methods of Rhinoplasty and is known as the Indian method of Rhinoplasty.

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In fact, Suśruta has dealt with all aspects of plastic surgery while describing the repair of ear lobules.

Note

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1 Śiravyadhaścikitsārdham śalyatantre prakirtitaḥ (Suśruta)

References

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Brown, J.B. and Mcdowell, P., Charles, C. Thomas : 1965, Plastic Surgery of the Nose, Springfield, ILL., USA.

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Guido, Majno :1977, *Healing Hand - Man and Wound in Ancient World*, Harvard Univ. Press, MA, USA.

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Jaggi, O.P. : 1973, *Indian System of Medicine*, Atma Ram and Sons, Delhi.

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Jolly, Julius E : *Indian Medicine*, Translated into English with notes from German by C G Kashiker, Poona, 1951; Munshiram Manoharlal, Delhi, 1977.

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Kutumbiah, P. : 1969, *Ancient Indian Medicine*, Orient Longman, Revised edition; First Edition 1962.

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Mukhopadhyaya, G.N. : 1923, *History of Indian Medicine*, 3 Vols, Calcutta University.

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Sharma, P.V. : 1972, *Indian Medicine in the Classical Age*, Varanasi.

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*Śuśruta Saṃhitā* with Commentary of Dalhana and Gayadāsa, (edited by) Jadavji Trikamji Acharya and Narayan Ram Acharya, Nirnaya Sagar Press, Bombay, 1938.

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