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History of plastic surgery in India. RE Rana, BS AroraDepartment of Plastic Surgery, Seth GS Medical College and KEM Hospital, Mumbai, India., India
Correspondence Address: Source of Support: None, Conflict of Interest: None Keywords: History of Medicine, 15th Cent., History of Medicine, 16th Cent., History of Medicine, 18th Cent., History of Medicine, 19th Cent., History of Medicine, 20th Cent., History of Medicine, Ancient, Human, India, Surgery, Plastic, history,
“Lives of great men all remind us, We can make our lives sublime; And departing leave behind us, Footprints on the sands of time.” -H.W.Longfellow. The earliest replantations were done by Lord Shiva by attaching an elephant’s head on his son’s body and by Ashwini Kumars who successfully replanted the severed head of Yagna. Thus the history of plastic surgery in India dates as far back or before the Vedic times nearly 4000 years ago. Brahma, the creator of the universe evolved, Ayurveda (the science of life) by meditation and imparted it to Daksha Prajapati, who in turn taught the Ashwini Kumars (twin gods). Lord Indra, the celestial ruler, learnt it from Ashwini Kumars and in turn passed on the knowledge to many rishis, namely, Sage Bharadwaja (Guru of Atreya), and King Divadaasa of Banaras (Lord Dhanvantri). Sushruta, who was Vishwamitra’s son, along with others approached Dhanvantri and requested him to accept them as his “shishyas” and teach them the science of Ayurveda. Sushruta Samhita is believed to be part of one of the four Vedas (part of Atharva-veda) and was written by Sushruta in approximately 600 BC compiling what he had learnt from his Guru Dhanwantri and his predecessors. It is said that Sushruta taught surgery at the Banaras University.[2] He has very succinctly described the reconstruction of the nose by cheek flap, repair of cut earlobe, piercing of earlobe, repair of cut lip, skin grafting, classification of burns, wound care and wound healing. Sushruta has been rightly called the “Father of Plastic Surgery” and “Hippocrates” of the 6th or 7th century BC. He described rhinoplasty for a cut nose as follows: [1],[2] 1) The leaf of a creeper, long and broad enough to fully cover the whole of the severed or clipped off part, should be gathered, 2) A patch of living flesh, equal in dimension to the preceding leaf should be sliced off from the region of the cheek. 3) After scarifying the severed nose with a knife, the flesh is swiftly adhered to it. 4) Insert two small pipes in the nostrils to facilitate respiration and to prevent flesh from hanging down. 5) The adhesioned part is dusted with the powders of Pattanga, Yashtimadhukam and Rasanjana pulverized together. 6) The nose should be enveloped in Karpasa cotton and several times sprinkled over with the refined oil of pure sesamum. 7) When the healing is complete and parts have united, remove the excess skin.” Even in those days he had emphasised the accurate cutting of the pattern to the size of the defect, the accurate cutting and suturing of the flap to the nose and maintaince of airway with tubes.[3] Frank McDowell has very aptly described Sushruta in the book “The source book of plastic surgery”[2] as follows: “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.”[2] There was a second method of rhinoplasty in India as practiced by Tilemakers. This involved using a free graft from the buttock. The skin and the underlying tissue of the shape of the defect on the nose was beaten with wooden slippers and applied on the defect with some “cement”.[4] In the 4th century, another scholar named Vaghbat wrote Ashtanga Sangraha and Ashtanga Hridyans. In Ashtanga Hridyans, he described rhinoplasty as done by Maharishi Atreya and emphasized the need for the provision of an inner lining by turning down the nasal skin.[3] The classical cheek flap rhinoplasty of Sushruta and Vaghbat was later modified by using a rotation flap from the adjacent forehead, The Traditional Indian Method of Rhinoplasty. This was kept a secret for centuries in India, and practiced by Marattas of Kumar near Poona, certain Nepaly families and Kanghairas of Kangra (Himachal Pradesh). [5] Dr. S. C. Almast personally met the last Hakim of Kangra, Mr. Dinanath Kanghaira whose family was practicing the art of rhinoplasty since the war of Kurukshetra and at Kangra since 1440 AD. Those with cut noses and deformed noses due to leprosy and syphilis were operated by them. The patient was given wine to drink to put him to sleep (since anesthesia did not exist in those days). A pattern of the defect was made on a paper. A handkerchief was tied around the neck to make the veins of the forehead prominent, and the flap was marked including the vein on the forehead (in the pedicle between the eyebrows). The forehead flap was folded in itself to form the inner lining. The knowledge of rhinoplasty spread from India to Arabia and Persia and from there to Egypt and Italy in the 15th century. The first translation of Sushruta Samhita was in Latin by Hessler in 1844 and in Arabic by Ibn Abi Usaybia (1203-1269 AD) and later into German by Vellurs. Bhishagratna translated it in English in 1907.[2] Although Britishers lived in India for a long time, they were not aware of Indian Rhinoplasty till 1793. Mr. James Findlay and Mr. Thomas Crusoe who were surgeons at the British Residency in Poona in 1793 witnessed the operation on “Cowasjee” and reported the details of the operation in the Madras Gazette. The same operation on Cowasjee was later published in Gentleman’s magazine, London, Oct. 1794 by a letter from Mr. Lucas[2] as follows: “Cowasjee, a Mahratta of the caste of the husbandmen, he was a bullock driver with the English Army in the war of 1792, and was made prisoner by Tipu Sultan, who cut off his nose and one of his hands. He joined the Bombay Army near Seringapatam. For about 1 year he remained without a nose, when he had a new one put on by a man of the Brickmaker (potter’s) caste near Poona”. Towards the end of the 19th century, two important works were published in India. One was titled “Rhinoplasty” by Tribhovandas Motichand Shah in 1889, who was then the Chief Medical Officer of Junagadh.[6] He described over a hundred cases treated by him in 4 years and gave minute operative details and discussed the advantages of forehead rhinoplasty. He used paper to make a pattern and used anesthesia. (Till now there was no mention of anaesthesia. Patients were just given wine to drink before surgery.) His name became a legend and it was said that “Kalu cuts the nose and Tribhovan reconstructs it”. Kalu was a local dacoit of that time who used to cut off people’s noses. The other book was “Rhinoplasty operations, with a description of recent improvements in the Indian method” by Keegan in 1900.[7] Even today, the western world gives credit to India for rhinoplasty called as the Indian Rhinoplasty. This of course, later received a few modifications, but the basic principles as laid down by Sushruta remain the same. Plastic Surgery in modem India owes a great deal to Sir Harold Gillies, Eric Peet and B.K. Rank for developing this speciality. In 1945, two Indian maxillofacial surgical units were established. No.l unit at Kirkee under Fitzgibbon and later under Gibson. No. 2 unit was at Secunderabad under Eric Peet. In 1946, Dr. C. Balakrishnan was posted at the No. 1 unit. The two units later merged to form a maxillofacial center for the Indian Army at Bangalore. In 1950, the first two Plastic Surgery departments were established in India. One at Patna under Dr. R. N. Sinha and the other at Nagpur under Dr. C. Balakrishnan. Sir Harold Gillies paid a visit to India and he was pleased with the work being done by Indian surgeons, especially Major Sukh, at the Armed Forces Medical College, Pune.[8] In 1955, the Govt. of India invited Mr. B. K. Rank, from Australia, to advise on the development of Plastic Surgery in India. He welcomed the idea of forming a plastic surgery section of Association of Surgeons of India. In 1957 Sir Harold Gillies visited India again. During his visit to Pune, he demonstrated various operations and techniques. He visited and lectured at several centres in various parts of the country, namely, Calcutta, Delhi, Patna, Jaipur and lastly Nagpur where he formally inaugurated the Plastic Surgery section of Association of Surgeons of India. The members were Dr. R. N. Cooper, Dr. C. Balakrishnan, Dr. M. Mukerjee, Dr. R. N. Sharma, Dr. N. H. Antia, and Dr. Hiveda.[8] The late Dr. C. Balkrishnan, was a devoted and dynamic plastic surgeon. He succeeded in establishing the first Department of Plastic and Maxillofacial surgery at the Govt. Medical College and Hospital, Nagpur. M. S. degree in Plastic Surgery was started in 1960, for the first time in India. Dr. Balkrishnan described Z-plasty for the nasal lining in cleft palate, classification of cleft lip and palate called as the “Nagpur Classification” and skin grafting in total avulsion of testes. In the same year, another department of Plastic Surgery was established at Patna under Dr. R. N. Sinha. Later, two more departments were started at Calcutta under Dr. M. Mukerjee and at Lucknow under Dr. R. N. Sharma. Dr. Antia, the 3rd generation trained Plastic Surgeon under Sir Harold Gillies worked at the Leprosy home in Khandala (near Pune) in 1958. He was the first surgeon to succeed in the integration of leprosy in general hospital practice. The unit at Sir. J. J. Hospital, Mumbai, was started in 1959 under Dr. N. H. Antia. In 1964, Tata Trusts provided a substantial grant to carry out two projects - one on Leprosy and other on Burns. The world’s first microvascular surgery on humans, a free flap transfer using microvascular anastomosis was done in 1966 by Dr. Antia and Dr. Buch (Scandinavian journal of Plastic surgery 1977). In 1961, another plastic surgery unit in Mumbai was established at K. E. M. Hospital, under Dr. Charles Pinto. Eric Peet from Oxford was a regular visitor to this department for the first 3 months. Dr. Pinto advocated one stage repair of cleft lip and palate, called as the “Hole-in-one” procedure. In 1964 one more department was started in Mumbai at G. T. Hospital, under Dr. R. J. Manekshaw. In 1963, Safdarjung Hospital, Delhi started a department of Burns, Plastic and maxillofacial surgery, with Dr. J. L. Gupta, as its head. Gradually, multiple centers in Plastic Surgery were established all over the country and various associations were formed. In 1971, Burns Association of India was formed during the 1st Congress of Burns at the J. J. Hospital. Dr. M. H. Keswani was the Secretary. Later under his leadership, the Burns Association flourished with contributions like potato peel dressings, prevention campaigns by way of radio and TV talks, small documentary ads, etc. “Pour water on Bums” has received worldwide popularity. In 1974, Indian society of surgery of the hand was formed with Dr. Ashok Sen Gupta as the president. A hand surgery unit was started at the Stanley Medical College at Madras under Dr. R. Venkataswami. Today it is one of the biggest and best hand surgery units in the world. Indian Society for Reconstructive Microsurgery was also formed at Madras in 1992 with Dr. R. Venkataswamy as the president. The contributions made by various Plastic Surgeons in India are numerous by way of devising new instruments, research and publications (papers and books). To mention all is beyond the scope of this paper. Today every state in India has multiple plastic surgery training centres. Each centre trains a number of postgraduate students every year who have spread all over India and abroad serving the community to their fullest. The specialty continues to grow and advance in all the fields of Plastic Surgery.
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