The Sushruta Samhita, an Ancient Indian Surgical Textbook, Counts 101 Blunt and 20 Sharp Instruments, Has Pupils Practise Cuts on Cucumbers and Gives the Steps for Rebuilding a Nose From Cheek Skin

The Sushruta Samhita is a Sanskrit surgical textbook that counts 101 blunt instruments and 20 sharp ones, tells pupils to practise cuts on cucumbers and water-bags before they touch a patient, and sets out how to rebuild a lost nose with skin from the cheek. Those details are in the English translation by Kaviraj Kunja Lal Bhishagratna, whose first volume the Internet Archive dates to 1907, and in the papers that quote it.

The National Council of Science Museums, in an online exhibit made at Science City in Kolkata, says the surviving text has 184 chapters and describes 1,120 illnesses. A 2009 editorial in the Indian Journal of Plastic Surgery gives the same two figures. A. O. Whipple, as quoted in papers by V. K. Raju (2003) and Sakti Das (2007), judged Sushruta the greatest surgeon of the pre-medieval period.

Two parts, and an Arabic translation by the eighth century

The text falls into a first part, the Purva-tantra, and a later one, the Uttara-tantra. At the end of the first part, Bhishagratna’s translation refers to “these one hundred and twenty chapters” and says topics left out will be taken up in the Uttara-tantra. Das lists the sections of the first part. Sutra-sthana has 46 chapters of basic principles and drugs, Nidana has 16 on how diseases arise, Sharira has 10 on the body and Kalpa has eight on poisons, and a fifth section, Chikitsa, covers treatment. Raju counts 18 chapters on the eye, describing 76 eye diseases, 51 of which need operations.

Loukas and colleagues, in the Journal of Anatomy, give the literal meaning of Sushruta as “one who has thoroughly learned by hearing”. The same paper says the first translation out of Sanskrit was into Arabic in the late eighth century, and that Latin, German and English versions followed. Raju spells the Arabic title Kitab-i-Susrud, and the museum exhibit spells it Kitab-ul-Susrud.

101 blunt instruments, 20 sharp ones

Chapter 7 of the first section counts 101 blunt instruments and says the hand is the most important of them, since none can be used without it. It sorts the rest into six groups: forceps shaped like a svastika (24 kinds), tongs (2), flat plates called tala (2), tubular instruments such as syringes (20), probes and bougies called shalakas (28) and accessory aids (25). The kinds add up to 101. The translation says they are made of iron, with another suitable material allowed where iron is not to be had.

The mouths of the forceps are meant to copy animals and birds. The text lists lions, tigers, wolves, hyenas, bears, jackals, deer, crows, vultures, falcons, owls, kites and herons among the models. A forceps of this class is to be 18 fingers long and is used to draw a thorn or other foreign matter out of bone.

Chapter 8 names the 20 sharp instruments, from the mandalagra and karapatra to the eshani, a probe whose tip is likened to the mouth of an earthworm. The translation sets out eight functions for them: incising, excising, scraping, draining, puncturing, extracting, probing and suturing. It says an instrument for draining or puncturing should be set with an edge as fine as a human hair, and one for excision with an edge as thin as a lentil seed. Instruments are to be tempered in alkali, water or oil.

Totals shift between counts. Das gives a higher figure, at least 125 instruments, including 28 kinds of catheters, sounds and irrigating syringes, and his paper does not say which edition he counts.

Practice on gourds, water-bags and a linen doll

Chapter 9 says a pupil who has read the whole of medicine is still not fit to treat a disease until he has practised. The teacher is to have him cut gourds, watermelons and cucumbers to learn incisions, and open a full water-bag, the bladder of a dead animal or a leather pouch of slime to learn excision. Scraping is practised on a piece of skin with the hair left on. Opening a vein is practised on the vein of a dead animal or on a lotus stem. Probing is taught on worm-eaten wood or a bamboo reed, extraction on the seeds of fruits such as the jackfruit and on teeth in a dead animal’s jaw, and draining on a plank coated with beeswax. Suturing is practised on cloth, skin or hide, and bandaging on a full-sized doll made of stuffed linen. The chapter ends by saying a physician who has tried his hand on such things will never lose his presence of mind in practice.

Two other chapters set the pupil’s duties. In chapter 2, the teacher addresses the new pupil before a sacred fire and tells him to help the poor, the helpless and travellers with his skill, and a bracketed gloss in the translation adds that no fee is to be charged. Chapter 10 says a physician should begin practice with the permission of the king of his country. The Charaka Samhita sets a similar charge in its own words, covered in our article on Charaka.

Rebuilding a nose, and mending ears

The nose repair sits at the end of chapter 16, which is mostly about piercing a child’s ears and mending torn lobes. The translation lists 15 ways to join a split lobe, ten workable and five seldom successful. One of the workable ones, the Ganda-karna, slices a patch of living flesh from the cheek and attaches it to the lobe.

Under the heading “Rhinoplastic operations” the text gives the nose repair in steps. A leaf of a creeper, big enough to cover the missing part, is gathered as a measure. A patch of living flesh of the same size is sliced from the cheek, scarified at the edges with a knife and joined to the cut nose. It is bandaged, and two small pipes go into the nostrils so the patient can breathe and the new flesh does not droop. The wound is dusted with powders, wrapped in cotton and sprinkled with sesame oil, and the patient drinks clarified butter. The exhibit by the National Council of Science Museums gives a different English rendering in which the flap keeps a small pedicle, a stalk of skin, attached to the cheek. The text says the new nose can be lengthened if it falls short or reduced if the flesh overgrows, and that the repair of a severed lip follows the same method without the pipes.

Loukas and colleagues add the context that the Laws of Manu, in their account, prescribed cutting the nose as punishment for adultery. They describe the repair as the equivalent of what surgeons now call a free flap. The Plastic and Reconstructive Surgery Global Open review of 2024 says that in some families in India and Nepal the method passed down in secret, and that it changed from a cheek flap to a forehead flap at a time and in a way that is not clear.

Das notes that the Italian surgeon Tagliacozzi later revived the technique, that the first English description appeared in The Gentleman’s Magazine in October 1794, and that plastic surgeons still call the pedicled forehead flap the Indian flap. He quotes Ackernecht as judging that plastic surgery in Europe, which flourished in medieval Italy, descends directly from classical Indian surgery. The 1793 operation near Pune that European surgeons watched is told in the first nose job.

Preparing a body to study anatomy

The section on the body, Sharira-sthana, tells anyone who wants thorough knowledge of anatomy to prepare a dead body and examine its parts. Loukas and colleagues quote a verse saying that what is seen directly and what the texts say, taken together, increase knowledge.

In Bhishagratna’s translation, the body chosen is to be complete, under 100 years old and not dead of poison or a long illness. The bowels are emptied, and the body is wrapped in grass sheaths, hemp or rope, kept in a cage and left to rot for seven days in a still pool. The observer then scrapes off the softened skin with a whisk made of grass roots, hair or split bamboo and examines the organs one by one. The translation that Loukas and colleagues quote says a slowly flowing river instead of a still pool, and seven nights instead of seven days.

Loukas and colleagues write that neither Sushruta nor Charaka shows any sign of dissecting animals, so the anatomical knowledge appears to come from human bodies. Bhishagratna’s translation gives the body 700 veins, 500 muscles, 900 ligaments, 300 bones and 210 joints. The Journal of Anatomy paper says critics put the bone count down to the large number of child bodies observed, whose bones had not yet fused. Das calls the anatomy inadequate by modern standards and quotes the translator Hoernle that its extent and accuracy are surprising for so early an age.

Eyes, bladder stones, fractures and childbirth

The eye chapters describe couching for cataract. In the passage Raju quotes, the patient sits on a high stool and looks at his own nose, the surgeon enters the white of the eye at a fixed point with a needle, and the right placement is shown by a sound and a gush of watery fluid. Breast milk is sprinkled on the eye, the patient blows down one nostril while the other is closed, and the eye is bandaged and examined every fourth day for 10 days. Raju and Raju write in 2017 that Sushruta may have been the first physician to operate for cataract this way. Couching pushes the clouded lens back into the vitreous cavity of the eye. They add that in 1752 Jacques Daviel reported removing cataracts through cuts in the cornea instead, with nearly 88 per cent favourable results in 206 consecutive patients.

Das reads chapter 7 of the Chikitsa section as setting out treatment of bladder stone, first with diet, fluids, alkali and instillations and then with perineal lithotomy, and says the text also describes the operation in women. The text warns that a surgeon who does not know the vulnerable parts of the region brings death to many innocent patients. For bones, the Indian Journal of Plastic Surgery editorial and the museum exhibit both count six kinds of dislocation and 12 of fracture, treated by traction, manipulation, apposition and stabilisation. In the section on diseases, Bhishagratna’s translation reads an instruction to remove at once the child of a mother who has just died in labour at term as a Caesarean section.

These passages describe a historical text and are not medical advice. For what trials say about Ayurvedic remedies today, see our review of the evidence.

How old is the text

The sources disagree. Loukas and colleagues say Sushruta is believed to have taught at Benares in the 6th century BCE, and also that his date has long been argued, that the original has not survived and that the text is known only from revisions and copies. They add that some place him near 1000 BCE on the strength of late Vedic hymns. Raju gives 800 to 600 BC, a 2024 Cureus review gives Kashi around 600 BCE, and Das says most Western Indologists place him between 600 and 1000 BC. The Cureus review and the 2009 editorial both use the title “father of surgery”; Loukas and colleagues use “father of Indian surgery”. Both are modern labels.

Nayana Sharma’s 2015 study sets out the layered readings. Bhishagratna put the original two centuries before the Buddha. P. V. Sharma separates four layers: Divodasa Dhanvantari in 1500 to 1000 BC, Sushruta in the 2nd century AD, the redactor Nagarjuna in the 5th century AD and Chandrata in the 10th. A chronology committee of the National Institute of Sciences of India proposed the 3rd or 4th century AD for Nagarjuna’s recension. The study adds that several men bore the name Nagarjuna and that G. Haldar and others reject any link between a Nagarjuna and the text. G. J. Meulenbeld, in the same account, dates the present text to about 500 CE as the work of an unknown author drawing on older sources, and does not accept separate layers.

The study also notes that Dridhabala, who completed the Charaka Samhita, is said to have used Sushruta’s work, which would put its first five sections before AD 300 to 500. A Sushruta appears in the Bower Manuscript, leading sages to the King of Kasi, but the study says the context and subject differ and that the manuscript does not deal with surgery. The earliest firm date any of these sources gives is the Arabic translation, made before the end of the eighth century CE.