The Sushruta samhita is in two parts, the Purva-tantra in five sections and the Uttara-tantra. Those two parts together encompass, apart from Salya and Salakya, the other specialities like medicine, pediatrics, geriatrics, diseases of the ear, nose, throat and eye, toxicology, aphrodisiacs and psychiatry. Thus the whole Samhita, devoted as it is to the science of surgery, does not fail to include the salient portions of other disciplines too. In fact, Sushruta emphasises in his text that unless one possesses enough knowledge of relevant sister branches of learning, one cannot attain proficiency in one's own subject of study. The Samhita is thus an encyclopaedia of medical learning with special emphasis on Salya and Salakya. The Sutra-sthana, Nidana-sthana, Sarira-sthana, Kalpa-sthana and Chikitsa-sthana are the five books of the Purvatantra containing one hundred and twenty chapters. Incidentally, the Agnivesatantra known better as the Charaksamhita and the Astangahrdaya of Vagbhata also contain one hundred and twenty chapters in all. The Nidana-sthana gives the student the knowledge of aetiology, signs and symptoms of important surgical diseases and those ailments, which have a bearing on surgery. The rudiments of embryology and anatomy of human body along with instructions for venesection (cutting of veins), the positioning of the patient for each vein, and protection of vital structures (marma) are dealt with in the Sarira-sthana. This also includes the essentials of obstetrics. Principles of management of surgical conditions including obstetrical emergencies are contained in the Chikitsa-sthana, which also includes a few chapters on geriatrics and aphrodisiacs. The Kalpa-sthana is mainly Visa-tantra, dealing with the nature of poisons and their management. Thus the Purva-tantra embraces four branches of Ayurveda. The Uttara-tantra, contains the remaining four specialities, namely Salakya, Kaumarabhrtya, Kayacikitsa and Bhutavidya. The entire Uttara-tantra has been called Aupadravika since many of the complications of surgical procedures like fever, dysentery, cough, hiccough, krmi-roga, pandu, kamala, etc., are briefly described here. The Salakya-tantra portion of the Uttara-tantra contains various diseases of the eye, the ear, the nose and the head. Thus the whole Samhita is one comprehensive treatise on the entire medical discipline.
On the whole, the entire Samhita is a complete work on medicine with special attention to Salya and Salakya tantras. The succinct and sombre style and the overall superiority of the Sushrutasamhita led to the extinction of other treatises which preceded this compilation or were contemporary. As a text-book, it is unrivalled in respect of composite teaching of the subject of surgery with reference to all allied branches of medical learning required by a surgeon. It is a forerunner of Vagbhata's Astanga-sangraha.
Sushruta has pointed out that haemorrhage can be arrested by apposition of the cut edges with stitches, application of styptic decoctions, by cauterisation with chemicals or heat. That the progress of surgery and its development is closely associated with the great wars of the past is well known. The vrana or injury, says Sushruta, involves breakdown of body-components and may have one or more of the following seats for occurrence, viz., skin, flesh, blood-vessels, sinews, bones, joints, internal organs of chest and abdomen and vital structures. Classically vrana, the wound, is the ultimate explosion of the underlying pathological structure. It is, in Sushruta's words, the sixth stage of a continuous process, which starts with sotha (inflammation). Sushruta says that in the first stage, the ulcer is unclean and hence called a dusta-vrana. By proper management it becomes a clean wound, a suddha-vrana. Then there is an attempt at healing and is called ruhyamana-vrana and when the ulcer is completely healed, it is a rudha-vrana. Sushruta has advocated the use of wine with incense of cannabis for anaesthesia.[3] Although the use of henbane and of Sammohini and Sanjivani are reported at a later period, Sushruta was the pioneer of anaesthesia.
Sushruta describes eight types of surgical procedures: Excision (chedana) is a procedure whereby a part or whole of the limb is cut off from the parent. Incision (bhedana) is made to achieve effective drainage or exposure of underlying structures to let the content out. Scraping (lekhana) or scooping is carried out to remove a growth or flesh of an ulcer, tartar of teeth, etc. the veins, hydrocele and ascitic fluid in the abdomen are drained by puncturing with special instrument (vyadhana). The sinuses and cavities with foreign bodies are probed (esana) for establishing their size, site, number, shape, position, situation, etc. Sravana (blood-letting) is to be carried out in skin diseases, vidradhis, localised swelling, etc. in case of accidental injuries and in intentional incisions, the lips of the wound are apposed and united by stitching (svana).
To obtain proficiency and acquiring skill and speed in these different types of surgical manipulations, Sushruta had devised various experimental modules for trying each procedure. For example, incision and excision are to be practised on vegetables and leather bags filled with mud of different densities; scraping on hairy skin of animals; puncturing on the vein of dead animals and lotus stalks; probing on moth-eaten wood or bamboo; scarification on wooden planks smeared with beeswax, etc. On the subject of trauma, Sushruta speaks of six varieties of accidental injuries encompassing almost all parts of the body.
Sushruta also gives classification of the bones and their reaction to injuries. varieties of dislocation of joints (sandhimukta) and fractures of the shaft (kanda-bhagna) are given systematically. He classifies and gives the details of the six types of dislocations and twelve varieties of fractures. He gives the principles of fracture treatment, viz., traction, manipulation, appositions and stabilisation. Sushruta has described the entire orthopaedic surgery, including some measures of rehabilitation, in his work.
As war was a major cause of injury, the name Salya-tantra for this branch of medical learning is derived from Salya, the arrow of the enemy, which in fights used to be lodged in the body of the soldiers. He emphasises that removal of foreign bodies is fraught with certain complications if the seat of the Salya be a marma.
Sushruta also discusses certain surgical conditions of ano-rectal region, he has given all the methods of management of both haemorrhoids and fistulae. Different types of incision to remove the fistulous tract as langalaka, ardhalangalaka, sarvabhadra, candraadha (curved) and kharjurapatraka (serrated) are described for adoption according to the type of fistula.
Sushruta was well aware of the urinary stones, their varieties; the anatomy of urinary bladder along with its relations is well recorded in the chapter on urinary stones. Varieties of stones, their signs and symptoms, the method of extraction and operative complication are given in detail. Apart from the above, surgery of intestinal obstruction (baddha-gudodara), perforated intestines (chidrodara), accidental injuries to abdomen (assaya-bhinna) in which protrusion of omentum occurs are also described along with their management.
Though the contributions of Sushruta are mainly in the field of Plastic and Cataract surgery,[1] a number of his other contributions to medicine are listed below:
Plastic Surgery
Sushruta lays down the basic principles of plastic surgery by advocating a proper physiotherapy before the operation and describes various methods or different types of defects, viz., (1) release of the skin for covering small defects, (2) rotation of the flaps to make up for the partial loss and (3) pedicle flaps for covering complete loss of skin from an area. He has mentioned various methods including sliding graft, rotation graft and pedicle graft. Nasal repair or rhinoplasty has been described in greater detail, which to this day has stood the test of time and is mentioned as the Indian method of rhinoplasty in the books of plastic surgery. Lastly, labioplasty too has received his attention. In short, all the principles of plastic surgery, viz., accuracy, precision, economy, haemostasis and perfection find an important place in Sushruta's writings on this subject.
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