“We are going for ‘Puttur Kettu’ “ I was puzzled when a patient with fracture of an arm bone said this, during my posting in Orthopedics. I was doing my Residency in surgery in JIPMER. Others told me that this was common. Puttur kettu was a traditional system of setting broken bones that was common all over South India. It is known after the place puttur in Andhra Pradesh, where it is practiced by healers of a particular caste. It is an art handed down over generations.
Dr. H Scott was an employee of the British East India Company in India of the closing years of the eighteenth century. He avidly followed Indian Traditional Medicine, and wrote regular reports to the Royal Society and the Royal College of Physicians of London. Scott heard about the nose reconstruction surgery done by Indian Surgeons. He finally got Mr. Findlay, a British surgeon, who had witnessed this, to write him a report. This was in pune.
The procedure was done on an employee of the British, whose nose was cut off by Tipu Sultan. The Surgery was done by some families of the Koomer (Potter) caste. In front of the astonished Findlay, an illiterate healer coolly, (with much composure, he writes), after giving the man liquor and restraining him, cut a pattern, and using this, raised a flap of skin from the forehead in the shape needed, and attached it to the freshened, re-created wound on the missing nose.
“My God- there is a nose!”- Thomas Cruso, another surgeon who was with Findlay, had exclaimed.
This inspired Joseph Carpue, FRCS, to do the first nose reconstruction using the median forehead flap, in Europe. A slight modification of this is one standard surgery done for nose defects today. I have done many. Every Plastic Surgeon practicing today would have done this wonderful surgery- originally, an Indian innovation.
Dr. Ekambaram, a doctor of modern medicine, describes a procedure, he witnessed in Coimbatore in 1910. Couching for Cataract. It was done by a travelling local craftsman. Cataract is an age related clouding of the lens of the eye, which eventually causes one to go blind. It was the commonest cause of blindness, before Cataract surgery became common. Now, it is done with sophisticated instruments, where, through a tiny hole, the clouded lens matter is liquefied and removed by an ultrasound probe, and a new, artificial folded lens is introduced, which unfolds inside the eye. But what is essentially needed is to remove the whitened lens, and this would instantly restore vision. What the practitioner did was to insert a probe with a rounded tip, penetrating the white of the eye, just by the side of the transparent cornea, at a particular angle, and push against the degenerated lens. This caused it to dislocate, and fall into the corner of the eyeball, and letting the light in through the pupil. For the man blind in both eyes, it restored vision instantly. What a dramatic event!
It was done by certain families of the ’Kayasth’ caste.
The couching witnessed by Ekambaram, is described exactly the same way, in Susruta Samhitha, a book on Surgery and Medicine, ascribed to the great Indian Surgeon from Kasi, Susruta. The method of nose reconstruction uses the naso-labial flap from the cheek, rather than the forehead. But essentially uses the same principles.
The book shown in the picture, ‘The Legacy of Susruta’ is basically a translation of the great text, with appropriate explanations, by Dr. M.S. Valiathan, a Cardiac Surgeon, Professor and academic. It is an interesting read, especially for Surgeons. By the way, it deals with a lot of Medicine, in addition to Surgery. I read it with relish. I also had an opportunity to interact with Dr. Valiathan, when he was a chief guest at the State Plastic Surgery conference at Kochi.
Susruta is dated by most scholars at around 300 to 500 BC. To put it in perspective, this is the same time when the 60 books called the Hippocratic corpus, attributed to Hippocrates, was written.
There is no doubt that Susruta Samhita is a magisterial work. It is not a record of Surgeries invented by the master. It is a compilation of all existing surgical knowledge of the times. The book starts with an introduction to Divadosa, guru to Susruta, and he studied Surgery (Salya) under him, along with five others as a batch. It was a pre-historic residency program.
Apart from Nose and The eye surgeries just described, there are innumerable accounts and detailed descriptions of bone setting, treatment of wounds and ulcers, obstetrics, and even a limited laparotomy, done sparingly and in a clearly specified manner. The surgery for bladder stone is almost the same as the one described in Europe, and against which Hippocrates cautions (Thou shalt not cut for the stone etc). It is likely that there were exchange of ideas between many parts of the world at this time.
It is not a complete system of Medicine or Surgery that can replace Modern Medicine. The entire information content is about one fourth or one fifth of ‘Baily’s Short Practice Of Surgery’, read by Medical students the world over. Outdated? Yes- all of it is. (You can differ with me on this- it is a personal opinion). But it is stupendous, considering the ancient era that it represents.
Are there clear superstitious elements in the Samhita? Oh yes. Just like any other literature of its time, there is.
Who can study Ayurveda? Only a Brahmin, Kshatriya or Vaishya. No Shudras, or any under that. That would exclude the bulk of the population. No women. Intelligence, empathy and good manners were essential, but so were, thin lips, a shapely nose and good looks!
The three doshas, vatha, pitha and kapha, are emphasized, just as Hippocrates did with his blood, black bile, yellow bile and phlegm. This can be taken as a sort of pseudo explanation by today’s standards.
Astrology was a big deal. Diseases of children were due to graham doshas (planetary problems). Insanity and epilepsy were classified as ‘bhoothvidya’- ailments caused by malevolent spirits or gods. Slokas and prayers had to be recited, and Brahmins had to pray for many a remedy to work.
In this, Hippocrates clearly differs. He even mentions epilepsy as a- “disease, though considered to be of divine origin, surely must have a physical abnormality as its ccause, just like other diseases”
But as far as Surgery was concerned, the ancient Indians were way ahead of the Europeans, in 500 BC. But Dr. Valiathan mentions, that the Susruta Samhita had a precursor, ‘the Susruta thanthra’, dated to the same period as Susruta. The Samhita was a later compilation, re-written in the first or second century AD, when the caste system had a strangle hold on Indian Society, and generally the society had stagnated to a great extent. The more unscientific elements were later added, according to Valiathan. The spirit of enquiry was lost, and by the time of the later Ashtangahridayam of 7th century AD by Vagbhata, all the surgical procedures were gone.
These manual, impure and unclean acts, along with arts and crafts, were delegated to the lower castes. The remnants as we have seen, survive to this day.
Remember that H. Scott, Findlay, and Joseph Purdue, though overlords of the Empire that ruled India, had no problem in learning from the natives. Is there a lesson here somewhere? I do believe so. (Jimmy Mathew)
