Sushruta’s approach to anaesthesia, although not as advanced as modern techniques, was innovative. He used herbal anaesthetics such as opium (Ahiphena) and cannabis (Vijaya) to manage pain, employing methods such as inhalation, oral consumption, and topical application. Proper preparation and dosage were crucial, and Sushruta provided detailed guidelines for extracting and administering these herbal remedies. He also employed complementary techniques, such as distraction and positioning, to enhance patient comfort. Despite limitations such as variable efficacy and the short duration of these anaesthetics, Sushruta’s methods laid an early foundation for the pain management practices seen in modern surgery. His foundational Ayurvedic text outlines the use of Madyapanam (intoxicating drinks such as wine) combined with herbal medicines (sedatives), including Cannabis sativa (Bhang), Acorus calamus (Vacha), Nardostachysjatamansi (Jatamansi), Hyoscyamus niger (ParasikaYavani), and others to induce insensibility and pain relief. Sushruta’s pioneering approach to pain management not only enabled over 300 types of surgical operations—including rhinoplasty, cataract extraction, and intestinal repairs—but also introduced the first systematic preoperative, operative, and postoperative protocols emphasizing patient comfort, safety, and consent.

According to the Bhoja-Prabandha (a 17th-century collection of stories), the 11th-century Paramara king Raja Bhoja underwent a successful brain surgery to remove a tumor. Two surgeons from Ujjain reportedly used anesthetic powder (moha-churna) to make him unconscious, opened his skull, removed the growth, and used a revitalizing powder (sanjivani) to wake him. King Bhoja had incurable headaches. All the doctors in the town tried their hands and nothing worked. Having heard about the king’s health problems two Brahmin surgeons from Ujjain came to Dhara and told the king that they can cure him but it involved surgery in the skull. The king told them that he was ready to undergo any difficulty to get out of this torturous headache.

The surgeons brought with them a herb called Sammohini which will put any one in a coma stage like the Chloroform of modern operation theatres. The surgeons know how much of herb to give for certain number of hours. Nowadays the anaesthetists stand by the surgeons to increase the level of chloroform or reduce it. But in those days the surgeons themselves handled this. When the operation was over they administered an antidote herb called Sanjeevini (we have already heard about it in Valmiki Ramayana which cured Lakshmana from Indrajit’s biological warfare). King Bhoja also went through all the procedures, and the surgery was 100 percent successful. He came out of the surgery room as if he had just woken up. This is in Bhoja Prabandham, a Sanskrit book giving his life history.

The modern era of anaesthesia in India began when James Esdaile practiced mesmerism-assisted surgery in Hooghly. However, ether soon took precedence due to its reliability.

James Esdaile (1808–1859)

In 1839, Assistant Surgeon Dr. James Esdaile, in the East India Company’s service, arrived in Hooghly, a town 38 km upriver of Kolkata (Calcutta), to work at Hooghly Hospital. Originally from Scotland—and with a degree in medicine from Edinburgh—Esdaile was advised that a warmer climate would better suit his delicate lungs. In Bengal, Esdaile read about mesmerism, or animal magnetism. The practice, first popularized by Franz Mesmer in the late eighteenth century and only becoming popular in Britain in the nineteenth century, was said to have anesthetic properties and could treat psychoses (“nervous” patients).

Textbook on Mesmerism as an anaesthetic and Curative agent by James Esdaile 1852

As Esdaile described in his book, “Mesmerism in India, and Its Practical Application in Surgery and Medicine,” in April 1845, a local man named Madhab Kaura was sent to him from Hooghly jail for scrotal surgery. Witnessing the patient’s suffering during the procedure, Esdaile allegedly “turned to the native sub-assistant surgeon, an student of the medical college, and asked him if he had ever seen Mesmerism? He said that he had seen it tried at the medical college, but without effect.”

Esdaile admitted that he only knew about the practice from reading, but felt there was nothing to lose by trying it. Although the dulling of pain and loss of senses took longer than he had hoped, it reportedly worked. “I placed [the patient’s] knees between mine,” he reported, “and began to pass my hands slowly over his face, at the distance of one inch, and carried them down to the pit of his stomach. This was continued for half an hour…” Though the pain dulling and sensory loss took longer than expected, it seemed effective. Esdaile even went so far as to “apply” fire to the patient’s knee to test the strength of the trance-like state. The patient remained free of pain.

Esdaile performed seventy-two more operations that year, using mesmerism as an analgesia. A government-appointed committee—composed of colonial Bengal’s most distinguished people, including magistrates and the Inspector General of Hospitals—then allowed him to run an experimental mesmeric hospital, subject to scrutiny from medical officers.

Esdaile’s practice was widely popular with “the natives,” as he termed them, and caused much fanfare. As historian of psychiatry Waltraud Ernst reports, he performed fantastical feats such as excising a tumor “7 feet in circumference and 2 feet at the neck,” seemingly without the patient feeling pain. Historian Alan Gauld writes that Esdaile conducted hundreds of surgeries and reported a 5 percent mortality rate (other techniques had a 50 percent or higher mortality rate).

Filarial scrotum Surgery done in 3 minutes by Dr James Esdaile with Mesmerism anaesthesia

Hooghly Hospital came to be called jadoo hospital (the word for “magic” in many Indian languages), less because they believed Esdaile was casting spells and more because of his own use of the phrase belatee munter, “the European Charm,” when explaining mesmerism to Indian assistants.

Breast tumour of 10lbs weight removed by James Esdaile by Mesmerism

Despite the initial approval for Esdaile’s experiments by the review committee, mesmerism was widely viewed as a pseudoscience that was nothing but a spectacle for the elite of Europe. At his experimental hospital, Esdaile hired native assistants to perform the mesmerism in his stead (he said the practice tired him excessively). The mesmerizer would take the patients to a dark room and blow over their bodies until they achieved a sleep-like state. Esdaile would come and confirm if the mesmerism was complete. Mesmerism could take days, if not weeks. Once achieved, Esdaile would perform the surgery. The doctors inspecting Esdaile’s work noted that each mesmerizer had their own way of performing the entrancement. It was impossible to standardize . But this wasn’t the only problem. The association of mesmerism with magic was too close. And Esdaile wanted to distance himself from faith healing and present mesmerism as a science.

He did this in part by treating “non-natives,” i.e., Europeans, to legitimize his practice as science. But he also made his practice open to public opinion and reported the results of his experiments in the local newspapers, all to ensure that his work was seen as a science. When Esdaile cured severe epilepsy of the wife of Hooghly’s Deputy Magistrate, Iswar Ghosals, his fame knew no end. Soon, never-ending queues at the hospital became a regular feature with everyone wanting to be part of Dr. Esdaile’s “miracle”.

The government learned about Esdaile’s successes in Hooghly, and decided to give him one year to practice in a controlled environment in Calcutta, where medical observers could watch his operations and write an official report on whether mesmerism worked. The result of the report was mixed; the Governor-General Lord Dalhousie, while generally supportive, decided that it was not worth continuing a Mesmeric Hospital on the government dime.

This is where it gets really interesting. In response to Dalhousie’s decision, the group of locals listed in the second image sent a petition to keep the hospital open – and when that didn’t work, they raised funds through public subscription to create a Mesmeric Hospital for Esdaile! This hospital was located in Creek Row in Central Calcutta, and opened on September 1, 1848. Unfortunately, it did not last long, and Esdaile returned to England in 1851.

The ultimate cause of the demise of Calcutta’s mesmeric hospital was twofold. First, mainstream medicine decided that mesmerism was no more than parlour tricks. And second, the invention of anesthesia made a reliable, much cheaper alternative to mesmerism available – and the East India Company of course went with the cost-saving option.

Most of Esdaile’s patients were Indians, drawn from the general or convict populations. In Mesmerism in India, he described those he treated as coming from a “feeble-minded, ill-nourished race, remarkably deficient in nervous energy.” Eventually, Esdaile’s mesmerism hospital failed due to factors more practical than magical: economics and scientific discovery.

Soft tissue sarcoma surgery by Dr James Esdaile by Mesmerism

Whatever its efficacy, mesmerism was a costly practice. Ernst writes that Assistant Surgeon Dr. Frederic J. Mouat, already a critic of Esdaile, calculated the hospital would incur a significant additional expense of 750 rupees per month with its use, as one mesmerizer was needed for every four patients.

In addition, ether and chloroform were in use by the late 1840s, and they were cheaper, more efficient, and aligned with orthodox Western medical practices. Even Esdaile had to concede, albeit reluctantly, that they were better.

Esdaile was made Presidency Surgeon in 1848, but his mesmeric hospital lost favor. He returned to Scotland in 1851. Though it’s not certain that subtropical Bengal had helped his lungs, Gauld suggests that Esdaile moved once more, south to Sydenham (London), as the Scottish climate “proved too bracing for the weak lungs which had sent him to India in the first place.” He died there in 1859 at the age of fifty-one.

The final conclusion of Mesmerism for surgery, according to Esdaile was “ I beg, to state, for the satisfaction of those who have not yet a practical knowledge of the subject, that I have seen no bad consequences whatever arise from persons being operated on when in the mesmeric trance.

Cases have occurred in which no pain has been felt subsequent to the operation even; the wounds healing in a few days by the first intention; and in the rest, I have seen no indications of any injury being done to the constitution.

On the contrary, it appears to me to have been saved, and that less constitutional disturbance has followed than under ordinary circumstances.

There has not been a death among the cases operated on.”


Hooghly Imambara ( James Esdaile had a hospital in this complex)

Quiz time

Who was the anaesthesiologist for Mahatma Gandhi’s emergent appendicectomy?

Answer – Dr. Date

History of Surgery ASI team

Dr Kaushik Bhattacharya (Head of the team)
Dr Pratap Varute
Dr Patta Radhakrishna
Dr Surajit Bhattacharya
Dr Clement Rajan
Dr K Lakshman
Dr Mahesh Prabhu

Susruta was probably the first surgeon in the world to classify and describe, in detail, surgical instruments, their methods of manufacture, quality control, maintenance, and their specific uses in the diagnosis and treatment of diseases. He was also the first surgeon to describe endoscopes such as rectal, aural, nasal, and vaginal specula. First evidence of brain surgery in Bronze Age Harappa is reported by A. R. Sankhyan and G.R Shug in a scientific correspondence to Current Science. The communication states that it is the first report of its kind to unequivocally present a case of ancient brain surgical practice, known as trepanation, observed 4300 years ago in a Bronze Age Harappan skull. A decade ago, a Neolithic skull from Burzahoma in the Kashmir Valley was reported to have multiple trepanations, the first case from the Indian subcontinent. Trepanation, also called trephination or trephining, has been the oldest craniotomic surgical procedure practiced by mankind since the Stone Age, involving drilling or cutting through the skull vault of a living or recently deceased person.

Blunt Instruments invented by Sushruta.

Sharp Instruments invented by Sushruta

Aggalayya’s Stone Inscription is a stone inscription in Telugu-Kannada Script is incised on three sides of a stone pillar set up in the village named Saidapur village, Yadgirigutta mandal (Bhuvanagiri Taluk), Nalgonda District of Andhra Pradesh. This inscription, which portrays the practice of surgery by select vaidyas in the medieval period, it evidenced by the subjoined inscription, which alludes the greatness of a surgeon named Aggalayya who flourished under the patronage of the Chalukya King Jayasimha II (A.D. 1015-1042) The mention of Aggalayya in an inscription, as a surgeon-physician in this context, shows that the practice of surgery was not completely given up by medieval period. It provides a glimpse of how surgeons and physicians held a high status during the reign of the Chalukya King Jayasimha. Aggalayya taught surgery to students from across India and served under four dynasties, earning the title 'Samanta Raja.'

Figure 1 – Aggalayya’s Stone Inscription (1034 AD to 1074 AD )

While specific, individualized tools used by Aggalayya are not listed in the provided text, his era practiced Sastra-vaidya (surgery) based on the principles of Sushruta Samhita. Archaeological findings from similar periods in South India, specifically the Taxila Museum, provide examples of the types of instruments used at that time:

• Maṇḍalāgra: A disc-shaped blade instrument.
• Eśaṇī: Surgical probes.
• Sūcī: Needles with eyes for suturing.
• Saṁdaṁśayantra: Gripping instruments or forceps.
• Tālayantra: Spatula-type instruments with handles.

These instruments, including those for cutting, probing, and suturing, were used for various procedures, including vascular, rectal, and ophthalmic surgeries.

Figure 2- Surgical instruments in the Taxila Museum.

Indian Surgical Instruments (published in the Indian Medical Gazette in 1877 )

Among the pioneers who defended the scientific heritage of Ayurveda during the colonial era, Vaidyaraj Prabhuram Jivanram (1832–1902) stands as a monumental figure. A scholar of Vedanta, practicing Ayurvedic Vaidya, and realized yogi, he worked to rescue Indian medical knowledge from distortion at a time when European narratives often dismissed India’s surgical achievements.
One of his most remarkable contributions is the rare monograph “Forceps Used by the Ancients of India” (Bombay, 1892), edited with notes by his erudite son Vishwanath Prabhuram Vaidya. Printed in English, Sanskrit, and Gujarati, it is among the earliest scholarly attempts to document, analyze, and defend India’s ancient obstetric and surgical instruments as described in the Sushruta Samhita and related traditions. Today, copies survive only in a handful of repositories, including holdings in London—making it a treasure of Ayurvedic and world medical history. In this extraordinary monograph, Vaidya Prabhuram challenges the assumption that obstetric instruments were purely European inventions of the early modern period. He compares Sushruta’s Sandamsa (extractive tongs) and Anigraha, along with related techniques of rotation, traction, and controlled extraction, with their European counterparts—arguing that classical Indian obstetrics documented sophisticated tools and methods long before they were widely recognized in Europe.
He writes with clarity and conviction:

“The application of forceps in case of difficult labor, the different turning, flexing, and gliding movements, and other obstetric operations… were first systematically described by Sushruta long before fillets and forceps were dreamt of in Europe, and thousands of years before Christ.”
— Prabhuram Jivanram Vaidya, Forceps Used by the Ancients of India (1892)

The medical students in ancient India were trained to perform real surgery by observing mock surgeries on gourds, watermelons, and cucumbers. These resident students were from the Sushruta school (6th century BCE) and were known as Saushrutas. The students were trained in surgery for a minimum of 6 years, during which they were taught the principles of the “Susruta Samhita.”

The image is from a 15th-century copy of the “Sushruta Samhita” kept at the Odisha State Museum, Bhubaneswar.

Quiz time

What were surgical instruments broadly classified into by Sushruta?

Answer – Yantra (blunt) and Shastra (sharp)

History of Surgery ASI team

Dr Kaushik Bhattacharya (Head of the team)
Dr Pratap Varute
Dr Patta Radhakrishna
Dr Surajit Bhattacharya
Dr Clement Rajan
Dr K Lakshman
Dr Mahesh Prabhu

Farrukhsiyar ( 1683 –1719), was the tenth Mughal Emperor of India from 1713 to 1719.In 1717, Farrukhsiyar issued a farman (royal order) giving the British East India Company the right to reside and trade in the Mughal Empire. They were allowed to trade freely, except for a yearly payment of 3,000 rupees. This was because William Hamilton, a surgeon associated with the company cured Farrukhsiyar of a disease.

10th Mughal Emperor Farrukhsiyar ( 1683 –1719)

William Hamilton was a Scottish surgeon, associated with British East India Company (EIC), who travelled to India in the first half of the 18th century. He was a part of the delegation that went from Calcutta, the base of the company, to meet Mughal emperor Farrukhsiyar in his court in Delhi in 1715. The surgeon was called to treat a swelling in the groin of the Emperor Farrukhsiyar, which he treated successfully. In October 1715, the emperor again suffered from violent pain and feared it would be a fistula. Hamilton's treatment was again successful. As a result, in December 1715 Emperor Farrukhsiyar was finally able to perform the wedding of his beloved daughter with the daughter of the Rajah of Jodhpur, which had been delayed by his recurrent illness

The Surgeon Hamilton received the professional charges for his royal treatment to the Emperor on the eve of wedding as “an elephant, a horse, five thousand rupees in money, two diamond rings, a jewelled aigrette, a set of gold buttons, and models of all his instruments in gold."

But not deeming these sufficient, Farrukhsiyar asked Hamilton to name any reward “he wished for”. The good surgeon, however, proved to be an extremely unselfish man. He immediately asked the emperor to grant the British East India Company mission the objective with which they had arrived from distant Calcutta. The company's delegation was placed in high regard in the royal court of Farrukhsiyar. In April 1717, the emperor's farman (grant) was issued, meeting all the requests that the company had made in its petitions. Permission was granted to purchase 38 villages surrounding the three already held by the company (Sutanuti, Gobindapur and Kalikata, the predecessor of modern Calcutta). The company was also granted trading privileges in Bengal and further fortification of Calcutta.This grant was instrumental in the setting up of business and the colonisation of Bengal, later to be followed by the rest of India, by the East India Company.

After the grant, Farrukhsiyar expressed his wish to retain William Hamilton in Delhi as his personal surgeon, but Hamilton refused to stay. Hamilton promised to the emperor that after a visit to Europe he would return and join him as his personal surgeon.

Hamilton died in Calcutta on 4th December 1717. He was buried at the churchyard of St. John's Church, Calcutta. The inscription tells the story of his curing a "Malignant Distemper" of Farrukhsiyar.

Quiz time

In 1645, Jahanara Begum, the favourite daughter of Mughal Emperor Shah Jahan, was severely burnt when her clothing caught fire in an accident during a dance performance.Local healers had failed to cure her, and, at the advice of vizier Assad Khan, the Emperor requested an English surgeon to treat Jahanara. Who was the surgeon?

Answer – Gabriel Boughton

Inscription stone

St John’s Church, Kolkata

History of Surgery ASI team

Dr Kaushik Bhattacharya (Head of the team)
Dr Pratap Varute
Dr Patta Radhakrishna
Dr Surajit Bhattacharya
Dr Clement Rajan
Dr K Lakshman
Dr Mahesh Prabhu

Jivaka, also known as Jivaka Komarabhacca, is revered as one of the earliest and most accomplished surgeons and physicians of ancient India. Flourishing around the 5th century BCE, he is best remembered as the personal physician of Gautama Buddha and the royal doctor to King Bimbisara of Magadha. Though Jivaka was the official personal physician of the Buddha. There is a saying that the Buddha did not make him a monk; he accepted him as his lay disciple because the Buddha wanted him to remain free to tend to sick people. Jīvaka was born in Rajagraha to a courtesan named Shalavati. Deemed unwanted, he was abandoned shortly after birth. Prince Abhaya, son of King Bimbisara, found the infant alive and adopted him—hence the name Jīvaka (“the living one”) and the epithet Komārabhacca (“raised by a prince”)

Educated at the legendary medical university of Takshashila, Jivaka mastered surgery, internal medicine, and herbal pharmacology. Ancient Buddhist texts credit him with performing complex surgical procedures, including abdominal surgery, cranial interventions, wound management, and treatment of intestinal obstruction—remarkable feats for his era.

Surgery for fistula-in-ano was performed on King Bimbisara. This is the procedure that made him famous, as though the surgery for fistula-in-ano was practiced before, but caused a high degree of incontinence. King Bimbisara, a husband to several young wives, became a subject of ridicule because of staining of his underclothes with blood. No royal physician would dare suggest an invasive procedure. Jivaka approached the king with an instrument called “nakha sastra” which has often been wrongly translated as a fingernail, but the actual instrument is one finger in breadth and two to nine fingers in length with a cutting edge. It appears that Jivaka probably made an incision into the fistula, which subsequently healed. The king was pleased with his “grandson” and appointed Jivaka as the royal physician. This eventually led to Jivaka becoming the physician to the Buddha himself. As Jivaka had cured the old king of his ailment, he was again offered payment, which was declined. The king thereupon gifted Jivaka a Palace with a garden full of mango trees and other fruit trees, and a small village within the district. Jivaka was to later build a monastery in this garden for Buddhist monks.(Jivakambhavana)

Craniotomy (Susabadho) to remove what were probably parasites (“panaka”) or clots was one of Jivaka’s other famous operations, which is mentioned in almost all the texts. He performed this on a merchant who was suffering from intense chronic headaches. Jivaka operated on a youth whose intestines had gotten “entangled.” and diagnosed as volvulus. Jivaka did a laparotomy, derotated the intestines, and sutured them back in their proper position. There is a similar description for a strangulated hernia.

A splinter of rock was embedded in Buddha's foot after being hurled by his rival, Devadutta. It was extricated using a small knife “Khaja” by Jivaka. Surgery for hydrocele by Jivaka was called as ‘andavuddhi’. The surgery involved opening the covering of the testicles and removing a hard “bija.”

Jivaka had come across a wealthy merchant whose wife had been unwell for seven years. He had gone to the merchant's house and announced that he was a Vaidya who had come to treat the patient. The merchant's wife had inquired from her security guard about the nature of the Vaidya who had come, and was informed that he was quite young. She had been treated by the most reputed scholars of the city and was hesitant to trust the youthful stranger. However, Jivaka had endeavoured to win her trust and had informed her that he would not request any payment to begin with, but with confidence had told her that she might pay him whatever fee she thought fit, once she was completely cured. With this, the merchant's wife had agreed to be treated by him. As had been taught him during his training, he was said to have firstly applied the technique of “Ashtavida Pariksha" – the eightfold method of examination of a patient. (This constituted examination of the nadi, that is the pulse, the mala, which is the bowel movements and excreta, the mutra, which is the urine, jinva, the tongue, and rupa the patient's body,etc.) Eventually, Jivaka diagnosed that the lady primarily needed treatment for the recurrent headaches. He treated her for a sinus condition with a nasya – an extract of herbs with ghee, and after a while her condition improved. He continued with treatment that completely rid her of her seven-year-long ailments. She was reported to have paid him in 16,000. Kahapanas, silver coins, and so did her grandson and his wife; and her husband gave her in addition, even more coins, servants, a horse and a carriage. Now enriched as he was, Jivaka returned to Magadha to the palace of Prince Abhaya.

There is a similar story that happened in Northern India when Jivaka was summoned by one of the kings who ruled the northwestern part of India, Sibi. A blind Brahmin approached King Sibi and asked for eye donation. The Brahmin asked him because the king had already earned the reputation of a big philanthropist, donating anything you ask for. The king sent a word for Jivaka, and he came and removed both the eyes of the king and fixed them to the Brahmin. This is recorded in the Buddhist chronicles. This is probably the first instance of the organ donation in those days.

Beyond technical skill, Jivaka embodied ethical medical practice. He treated the poor without charge, emphasized compassion toward patients, and integrated moral responsibility into medical care. His approach aligns closely with modern principles of medical ethics, beneficence, and patient-centered care.

Jivaka is also regarded as a pioneer of traditional Indian medicine, influencing early Ayurveda and Buddhist medical traditions across Asia. In many Southeast Asian countries today, he is still venerated as the “Father of Medicine” and a patron saint of healers.

In essence, Jivaka represents the timeless ideal of the surgeon-scholar—scientifically skilled, ethically grounded, and deeply humane—a legacy that continues to inspire modern surgical practice.

The remains of Jivaka’s vihara in the city of Rajgir (Bihar) are still visited by hundreds of people from all over the world.Jīvaka thus occupies a foundational place in the history of Indian surgery—not merely as “the Buddha’s doctor,” but as the earliest historically contextualized exemplar of the Indian surgical tradition. Jivaca is considered as the father of traditional Thai Medicine.

Quiz time
What is one of the most famous surgical procedures Jivaka is credited with performing?

Answer: Surgery for fistula-in-ano on King Bimbisara.

Reference:
1. Zysk KG. Asceticism and Healing in Ancient India: Medicine in the Buddhist Monastery. Oxford: Oxford University Press; 1991.
2. Meulenbeld GJ. A History of Indian Medical Literature. Groningen: Egbert Forsten; 1999–2002.
3. Filliozat J. The Classical Doctrine of Indian Medicine: Its Origins and Its Greek Parallels. Delhi: Munshiram Manoharlal; 1964.
4. Wujastyk D. The Roots of Ayurveda. London: Penguin Classics; 2003.
5. Basham AL. The Wonder That Was India. London: Sidgwick & Jackson; 1954.
6. Bhishagratna KK, trans. The Sushruta Samhita. Varanasi: Chowkhamba; 1907.

History of Surgery ASI team

Dr Kaushik Bhattacharya (Head of the team)
Dr Pratap Varute
Dr Patta Radhakrishna
Dr Surajit Bhattacharya
Dr Clement Rajan
Dr K Lakshman
Dr Mahesh Prabhu

Sushruta defined surgical acumen as – “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.”

Sushruta defined surgical acumen as – “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.”

The first complete English translation – Kaviraj Kunja Lal Bhishagratna ,1907 Calcutta

Sushruta Samhita is a collection of surgical and allied knowledge, written in two parts, the Purva-tantra and Uttara-tantra. Purva-tantra has 120 chapters in five sections – Sutra-sthana, Sarira-sthana, Nidana-sthana, Chikitsa-sthana and Kalpa-sthana. The Chikitsa-sthana deals with surgical conditions including obstetrical emergencies, geriatrics and aphrodisiacs. The Kalpa sthana contains visha tantra which describes the nature of poisons and their management. Uttara-tantra covers Salakya, Kaya-chikitsa, Kaumarabhetya and Bhutavidya and Aupadravika, the description of many complications of surgical procedures like hiccough, fever, krmiroga, pandu, dysentery, cough, kamala, etc. The Salakyatantra has description of the various diseases of eye, ear, nose and head. The two parts together cover, apart from surgery, other specialities like medicine, paediatrics, geriatrics, diseases of the ear, nose, throat and eye, toxicology and psychiatry. The Sushruta Samhita describes over 300 surgical procedures and classifies human surgery under eight heads – Chedya (excision), Lekhya (scarification), Vedhya (puncturing), Esya (exploration), Ahrya (extraction), Vsraya (evacuation) and Sivya (Suturing). There are detailed descriptions on methods of haemostasis and leech therapy.

Like a true innovator. Sushruta designed his own instruments and did so by understanding his own needs as well as the utility of the beaks and claws and jaws of birds and animals, and naming his instruments after them. His Samdamsa yantras are the first forms of the modern surgeon's spring forceps and dissection and dressing forceps. In fact, his system of naming surgical tools after the animals or birds they resemble in shape, for example crocodile forceps, hawkbill forceps, is adopted even today. What is to be appreciated is not just the ingenuity of Sushruta but also the progress which research in metalurgy had made in India, way back in 600BC!

Instruments designed by Sushruta

The Sushruta Samhita thus is a comprehensive surgical textbook describing in detail general surgical techniques of making incisions, probing, extracting of foreign bodies, alkali and thermal cauterisation, tooth extraction, excision, the use of trocars to drain abscess, hydrocele and ascitic fluid, methods to stitch the intestines using ant-heads as stitching material, more complex procedures including removal of the prostate gland, urethral stricture dilatation, extraction of urinary bladder stone, hernia surgery, Caesarean section, management of hemorrhoids, fistulae, laparotomy and the management of intestinal obstruction, perforated intestine and accidental perforation of the abdomen with protrusion of omentum. Orthopaedic surgery, including management of dislocation of joints (sandhimukta) and fractures of the shaft (kanda-bhagna) bones and their reaction to the injuries, principles of fracture management, viz., traction, manipulation, appositions and stabilization including some measures of rehabilitation and fitting of prosthetics are all described. Ophthalmic surgery for various eye diseases, medical or surgical interventions including cataract surgery have also found a place in it. It also deals with dissection and the study of the anatomy of the human body, and even embryology and sequential development of the structures of the foetus!

Incision making, wound care and wound closure all find their due place in Sushruta Samhita. ‘Chedan Karma’ (Incision), according to Sushruta are mainly of three types – on head, eyelid, cheek, frontal region, lips, gums, axilla, hip joint – ‘Triyaka cheda’ means oblique incision, over upper and lower limb – ‘Chandramandal’ incision (Circular) and over anal region and penis incision should be ‘Ardhchandrakruti’ (Semicircular). He further went on to mention that if these rules of incision were not followed there were chances of injuring vital structures, delayed wound healing (Chirad Vranasanroho) and formation of keloid (Mamsakandi). Also while describing incision on breast abscess (StanaVidradhi) Sushruta has mentioned that incision should be taken such that it should avoid Papillary duct and areola otherwise there are chance of formation of sinus (Nandivrama).

While describing wound management (vrana-chikitsa) Sushruta has described sixty types of treatment (Shashthiupokrama). Interestingly, wound scrapping (lekhana) is mentioned as sixteenth upakrama. Thereafter before suturing wound should be thoroughly cleaned otherwise there will be chances of pus formation in wound. He mentioned that wounds with hard fatty mass should be scrapped. Scrapping should be such that edges of wound should be at equal level (Vartmanamtupramanenasamam). Thereafter before suturing wound should be thoroughly cleaned otherwise there will be chances of pus formation in wound. In Shashitiuparamas (Sixty methods) he described sixty types of treatments for different types of wounds and their treatments – Nirvapan, Vtkarika, Utsadan and Avasadan being a few treatments for large wound. The basic principles of wound care still remain the same even after so many years!

Sushruta has given detailed description of various techniques of wound closure. He mentioned four types of suturing – Vellitaka, Gofanika, Tunnasevani, Rujugranthi which should be used for different parts of body. He has also mentioned different types of needles to be used to different areas for wound closure. For areas which is less fatty in nature and over joints, round body two finger long needle (Vrultanguladwgyam) should be used while in areas with more fats – cutting body, three finger long triangular (Ayata tryangula tryastra) needle should be used and in areas where vital organs are nearby curved (Dhanurvakra) needle should be used.

His "paschat-karman" or post-operative schedule included the scar management protocols, rehabilitation and removal of complications. Fourteen types of bandaging capable of covering almost all the regions of the body and different methods of dressings with various medicaments are mentioned in Sushruta Samhita. Evidence points to a knowledge of Medhumeha (diabetes) and other co morbid conditions that can influence surgery!

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.’ – Dr Frank McDowell

Reference:
Bhattacharya S. Sushrutha – our proud heritage. Indian J Plast Surg. 2009
Jul;42(2):223-5. PMID: 20368862; PMCID: PMC2845369.

Quiz question

How was Venesection being taught at the time of Sushruta?

Answer

At the time of Sushruta (6th century BCE), venesection (Sira Vyadha), a critical method of bloodletting (Raktamokshana), was taught through a rigorous, practical, and simulation-based approach, emphasizing hands-on experience before practicing on patients. To teach the precise technique of venesection, students practiced on the stalks of water lilies (specifically Kamala and Kumuda). The soft, tubular structure of the lily stalks provided a realistic model for manipulating and puncturing veins without risk to a patient.

History of Surgery ASI team

Dr Kaushik Bhattacharya (Head of the team)
Dr Pratap Varute
Dr Patta Radhakrishna
Dr Surajit Bhattacharya
Dr Clement Rajan
Dr K Lakshman
Dr Mahesh Prabhu

The Department of Science & Technology (DST), under a programme called Science Heritage & Research Initiative (SHRI) has sanctioned a grant to a group of plastic surgeons, historians, Sancrit scholars and other affiliated domain expertd to dig into the history and gather some tangible evidence about the life and time of the great sage Sushruta. The fact that he was the ‘father of Plastic Surgery’ and his devised method of reconstructing a cut nose is still practiced today and the world calls it the ‘Indian Rhinoplasty’ is no longer debated. A statue of this great sage has found a proud place in the foyer of the Australian College of Surgeons in Melbourne and many medical institutions in India acknowledge his contribution by putting us his statues and paintings in their premises, a giant one in the garden of Amrita Institute of Medical Sciences in Cochin being the most eye catching.

Sushruta is believed to be the son of a sage Vishwamitra and disciple of guru Divodas or Dhanvantari, the King of Kashi. History dates him to 600 BC-1000BC in the Vedic times, placing him on the time line, a millennium before the Greek physician Hippocrates and two millennia before another Greek, Galen and Roman,Celsius! It is today hard to believe that even as way back as 600BC a man performed complex surgical procedures including reconstruction of the nose by cheek flap, repair of cut earlobe, piercing of earlobe, repair of cut lip and skin grafting with medieval instruments that he himself manufactured. Not only does it say volumes about the quality of medicine being practiced then but also about the quality of metallurgy and engineering which must have coexisted in order to make the variety of instruments which Sushruta had designed after watching closely the beaks of birds and paws and jaws of animals!

Sushruta is said to have compiled a monumental thesis in surgery, the ‘Sushruta Samhita’. It is the oldest known surgical text and it describes in exquisite detail the examination, diagnosis, treatment and prognosis of numerous ailments, as well as procedures of plastic surgery, including reconstructive surgery and rhinoplasty. Written in Sanskrit in the form of Shlokas, verses and incantations, gilded by the flowery language and metaphors characteristic to Sushruta, the Samhita was not an easy text to decipher. It is regarded to be a part of Atharva Veda and the access to the Vedic knowledge was restricted to select few scholars of the ancient times. Such social factors may have contributed to the lack of dissemination of this ancient knowledge in India leading ultimately to our dependence on the Western world for our surgical know-how. The ancient Indian medical practitioners were divided into two classes: the Salya-cikitsakas (surgeons) and the Kaya-cikitsakas (physicians) but for a surgeon the knowledge of both the fields was essential.

While we will talk about the Sushruta Samhita in great details in the next issue, it is pertinent to mention that in this unique document Sushruta has described Anatomy, Physilogy, Surgery, Orthopaedics, Obstetrices & Gynaecology, Embryology, Opgthalmology and Urology in great details. Sushruta did not limit his teachings to procedures; he also described surgical instruments, catheters, sounds and irrigating syringes. He gave details of their manufacture (including the metal to be used and the measurements) and maintenance (cleaning by caustics and alkalis).

Treatment was not confined to surgery alone but there are descriptions on comprehensive perioperative care. Sushruta remarks: "the patient who has been fed, does not faint, and he who is rendered intoxicated, does not feel the pain of the operation." There is evidence of usage of wine and cannabis incense for inducing anaesthesia before surgery. So Sushruta can be safely considered to be ‘the father of Anaesthesiology’ as well!

He made his disciples practice their surgical skills on various experimental models, like incising on watermelon, gourd, clay pots and reeds, probing on worm eaten wood, just like in present day simulation skills workshops. So, practicing ob Surgical Simulators, which the wortld is rediscoverig today, had its initiation in the hands of Sushruta. Sushruta insisted on a sound knowledge of anatomy (Sharirasthana) and embryology in surgical practise and studies were conducted on decomposing cadavers and dead foetuses towards this aim.

Fourteen types of bandaging capable of covering almost all the regions of the body were described for the practice of the student on dummies. The use of surgical devices such as tourniquets and setting plasters also find a mention. Some important procedures, which preceded actual surgery, such as cauterisation by Ksaras (alkaline substances) or Agni (fire – heat) and application of leeches were being practiced extensively by him.

Apart from his surgical prowess, Sushruta was also a staunch proponent of good ethics, attitude and communication skills in surgical aspirants. According to him, "He is a good surgeon, who possesses courage and presence of mind, a hand free from perspiration, tremor-less grip of sharp and good instruments and who carries his operations to success and the advantage of his patient who has entrusted his life to the surgeon. The surgeon should respect this absolute surrender and treat his patient as his own son." Sushruta laid down the pre requisites for a qualifying surgeon as”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". He warns that improper intervention with surgical manoeuvre due either to ignorance of the progress of the disease process, greed for money or lack of judgment, lead only to complications. With such high standards set by the master surgeon and teacher, this era was regarded as the golden age of surgery in ancient India.

Sushruta had realized the importance of balance in knowledge and skill. In the Samhita he mentions, "a physician, well-versed in the principles of science of medicine but incompetent in his art because of want of practice, as well as the physician, experienced in his art but short on the knowledge of Ayurveda, is like a one-winged bird that is incapable of soaring high in the sky".

Sushruta remains our proud heritage and Sushruta Samhita is a living testament to his outstanding brilliance and colossal contribution to the science and art of healing. It is a pity that despite knowing a fair bit about this sage, teacher and exponent of surgical practice, there are still gaps in our trail of knowledge which only tangible evidence would be able to fill. Let us try to fill these missing gaps. I also invite you to watch a movie which the Association of Plastic Surgeons of India produced on Sushruta:

https://www.youtube.com/watch?v=rCFtR92JS-c

Reference:
Bhattacharya S. Sushrutha – our proud heritage. Indian J Plast Surg. 2009
Jul;42(2):223-5. PMID: 20368862; PMCID: PMC2845369.

Quiz time

What was the modern upper GI endoscope known during the time of Sushruta ?

Ans Nadiyanta

History of Surgery ASI team

Dr Kaushik Bhattacharya (Head of the team)
Dr Pratap Varute
Dr Patta Radhakrishna
Dr Surajit Bhattacharya
Dr Clement Rajan
Dr K Lakshman
Dr Mahesh Prabhu