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Monday, April 7, 2014

plastic surgery

Sushruta Samhita

The Sushruta Samhita(सुश्रुतसंहिता) is a Sanskrit redaction text on surgery. The original work is attributed to Sushruta, likely a historical physician from the 6th century BCVaranasi,[1][2][3] although the text as preserved dates to the 3rd or 4th century AD. It is one of three foundational texts of Ayurveda(Indian traditional medicine), alongside the Charaka Samhitaand the medical portions of theBower Manuscript.[4] The original text however is lost and modifications and edited versions are currently available (Ruthkow IM (1961) Great Ideas in the History of Surgery, pp. 57. Baltimore: The Williams & Wilkins Company. in Anatomy in ancient India: a focus on the Susruta Samhita Journal of Anatomy 2010)

The Sushruta Samhita, in its current form, contains 184 chapters and description of 1120 illnesses, 700 medicinal plants, 64 preparations from mineral sources and 57 preparations based on animal sources.[1] The text discusses surgical techniques of making incisions, probing, extraction of foreign bodies, alkali and thermal cauterization, tooth extraction, excisions, and trocars for draining abscess draining hydrocele and ascitic fluid, the removal of the prostate gland, urethral stricture dilatation, vesiculolithotomy, hernia surgery, caesarian section, management of haemorrhoids, fistulae, laparotomy and management of intestinal obstruction, perforated intestines, and accidental perforation of the abdomen with protrusion of omentum and the principles of fracture management, viz., traction, manipulation, appositions and stabilization including some measures of rehabilitation and fitting of prosthetics. It enumerates six types of dislocations, twelve varieties of fractures, and classification of the bones and their reaction to the injuries, and gives a classification of eye diseases including cataract surgery.

The text was translated to Arabic as Kitab-i-Susrud in the 8th century.

The Sushruta Samhita is divided into two parts. The first is the five section Purva-tantra, and the second is the Uttara-tantra. Together, the Purva-tantra and Uttara-tantra (apart from Salyya and Salakya) describe the sciences and practices ofmedicinepediatricsgeriatrics, diseases of the ear, nose, throat and eye, toxicology, aphrodisiacs and psychiatry.

  • The Purva-tantra is dedicated to the four branches of Ayurveda. It is divided into five books and 120 chapters (It is noteworthy that theAgnivesa-tantra, better known as the Charaka Samhita and the Ashtanga Hridayam of Vagbhata, is also divided into 120 chapters). These five books are the Sutra-sthana,Nidana-sthanaSarira-sthanaKalpa-sthana andChikitsa-sthana. The Nidana-sthana is dedicated to aetiology, the signs and symptoms of important surgical diseases and those ailments which have a bearing on surgery. The rudiments of embryology and the anatomy of the human body, along with instructions for venesection, 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. The Chikitsa-sthana describes the principles of management of surgical conditions, including obstetrical emergencies, including chapters on geriatrics and aphrodisiacs. The Kalpa-sthana is mainlyVisa-tantra, dealing with the nature of poisons and their management.
  • The Uttara-tantra contains the remaining four specialities, namely Salakya,Kaumarabhfefefrtya,Kayacikitsa and Bhutavidya. The entire Uttara-tantra has been called Aupadravika, since many of the complications of surgical procedures as well as fever, dysentery, cough, hiccough,krmi-rogapandukamala, etc., are briefly described here. The Salakya-tantra portion of the Uttara-tantra describes various diseases of the eye, the ear, the nose and the head.

The Samhita is dedicated to other disciplines as well. Sushruta emphasizes that unless students possess enough knowledge of relevant sister branches of learning, they cannot attain proficiency in their own subject of study. The Samhita represents an encyclopedic approach to medical learning, with special emphasis on Salya and Salakya, and can be thought of as a comprehensive treatise on the entire medical discipline.

Surgical procedures described

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 ofcannabis for anaesthesia.[4]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 aslangalakaardhalangalaka,sarvabhadracandraadha(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.

The samahita 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. Reconstruction of a nose (rhinoplasty) which has been cut-off, using a flap of skin from the cheek has been described. Labioplasty too has received attention in the samahita.

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