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History of Technology in India, Vol. I: From Antiquity to c. 1200 A.D. v1.c21.s4: Clinical Surgery by Suśruta

History of Technology in India, Vol. I: From Antiquity to c. 1200 A.D. v1.c21.s4

Language
English

Contents

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.

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