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| REVIEW ARTICLE |
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| Year : 2020 | Volume
: 8
| Issue : 1 | Page : 10-13 |
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A critical review on Sushruta’s surgical ethics
Pooja P Shrivastav, Kiran Khandare
Department of Shalyatantra, Mahatma Gandhi Ayurved College Hospital and Research Centre, Datta Meghe Institute of Medical Sciences (DU), Wardha, Maharashtra, India
| Date of Submission | 15-Mar-2020 |
| Date of Decision | 08-May-2020 |
| Date of Acceptance | 13-May-2020 |
| Date of Web Publication | 2-Jul-2020 |
Correspondence Address:
Pooja P Shrivastav
Department of Shalyatantra, Mahatma Gandhi Ayurved College Hospital and Research Centre, Datta Meghe Institute of Medical Sciences (DU), Wardha, Maharashtra.
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/JISM.JISM_5_20
Ethics is the branch of philosophy, which involves systematizing, defending, and recommending concepts of right and wrong conducts for the individual and for the society. It establishes the nature of obligations, or the duties that people are obliged to themselves and to one another. Sushrut Samhita is considered to be the oldest literature available for surgery, wherein Acharya Sushrut has emphasized various surgical ethics in the form of Sadvrutta. This study was aimed to explore the ethics of surgery (Shalyakriya) mentioned by Acharya Sushrut. The method followed for this was thorough analysis of Sushrut Samhita and Internet surfing from various research articles. It was found that in Sushrut Samhita, the maximum information pertaining to ethics of surgery was mentioned in Sutrasthan, and the main concern of Sushrut behind explaining all the ethics was utmost care of the patient by creating efficient surgeons. The ethical concept described by Sushruta includes general ethics; professional and academic ethics; preoperative, operative, and postoperative ethics; ethics of experimental surgery; and ethics in emergency. The concepts described by him are valid even in current clinical practice today. Keywords: Acharya Sushruta, Ethics, Philosophy, Sadvrutta, Surgery
How to cite this article:
Shrivastav PP, Khandare K. A critical review on Sushruta’s surgical ethics. J Indian Sys Medicine 2020;8:10-3 |
| Introduction | |  |
Ethics is derived from a Greek word “Ethos,” which means character. Ethics is a branch of philosophy that simply means the rule or principles, which govern right conduct.[1] It is an essential supporting discipline in the practice of surgery. Ethics and surgical intervention must go hand in hand. In the field of surgery, Sushrut Samhita is considered to be the prime literary resource.
Ethical principles expressed and practiced in ancient period were of high test order. In Sushrut Samhita, there is no separate section on ethics. To learn the surgical ethics given by Acharya Sushrut, it was important to distill the ethical content from various sections of Sushrut Samhita.
| Materials and Methods | | |
This study was aimed at exploring the ethics of surgery (Shalyakriya) mentioned by Sushruta. The method followed for this was thorough analysis of Sushrut Samhita and various research articles published.
| Observations | | |
After analyzing Sushrut Samhita, it can be concluded that the ethical principles can be classified into eight groups in the following order:
- General ethics—Samanya Sadvrutta
- Professional and academic ethics—Vyavsayik and Shaikshanik Sadvrutta
- Preoperative ethics—Purvakarma Sadvrutta
- Operative ethics—Pradhankarma Sadvrutta
- Postoperative ethics—Paschatkarma Sadvrutta
- Ethics and importance of experimental surgery—Yogyakaran Sadvrutta
- Quacks—Kuvaidya Vrutta
- Ethics in emergency—Aatyayik Sadvrutta
General Ethics—Samanya Sadvrutta
Sushrut dealt with three essential aspects before a doctor was entitled to surgical practice.
- Complete medical education: One can start practice only after obtaining thorough knowledge of science of medicine, having observed and performed the operation themselves, having successfully passed all the appropriate exams, and after getting permission from the government.[2]
- External appearance: The hair should be cut short, and the nails should be pared. Personal hygiene and cleanliness should be taken care of. One should wear white and sober dress.[3]
- Personal behavior: On visit, one should go with a cool balanced mind, wishing everybody without trying to show off, and with an attitude of helping all. One should be accompanied by an able assistant.[3]
Patients may have hesitation with their relatives, their sons, and even with their parents, but they have full trust in the physician. They give themselves up in the doctor’s hand, and have no uncertainties about the doctor. Therefore, it is the duty of the physician to look after the patient as their own son.[4]
According to Sushrut, surgeons while performing surgeries should possess the praiseworthy qualities such as courage, quickness, sharpness of instruments with confidence, and no sweating or trembling of hands.[5]
Professional and Academic Ethics—Vyavsayik and Shaikshanik Sadvrutta
The person who is well versed in practical as well as descriptive anatomy only they can be considered as expert surgeon. Hence, one should start practicing surgery after clearing away the fears by actually observing the surgical anatomy and reading concerned suitable literature.[6]
Thorough knowledge of drugs for their taste, medicinal properties, potency and reactionary effects tissues and excretory products, vital organs, vessels, nerves, joints, bones, cartilage, developmental factors of the fetus, extraction of foreign body, differential diagnosis of wounds, varieties of fracture and dislocation, curability, palliative and incurability of the diseases and what to speak of men with lesser intelligence and many of such other problems should be considered. Hence, it is very essential for the teachers to elucidate thoroughly each verse, and for the students to listen to these courteously.[7]
Person with knowledge of only one branch of science cannot reach a proper conclusion, therefore a physician should try to learn as many related sciences as possible.[8]
Acharya alleged that the one who has only theoretical knowledge but who is not so good in practical work will get mystified at being confronted with a patient, in the same way as a coward feels on the battlefield.[9]
One who is good in practical work but lacks theoretical knowledge is not respected in the cultured society and deserves punishment from the government.[10]
Only the intelligent person who knows both theory and practical work is capable of obtaining success, in the same way like only two-wheeled vehicle is useful in the battlefield.[11]
| Classification: Preoperative, Operative, and Postoperative Stages | | |
Sushrut, classified complete surgical treatment into three stages, namely Purvakarma (i.e., preoperative), Pradhankarma (i.e., operative), and Paschatkarma (i.e., postoperative).[12]
Preoperative Ethics—Purvakarma Sadvrutta
Before initiating the treatment of a patient, their expectancy of life must be determined by the physician. In hopeful cases, the examination should be conducted along these lines—nature of disease, residence and seasonal variations, appetite, age, physical condition and general health of the body, psychological aspects, articles that suit their constitution and those to which they are sensitive, temperament of the patient, and consideration of appropriate treatment.[13]
Any type of treatment should be decided only after considering the strength of the disease, condition of the patient, and their digestive and metabolic strength.[14]
When death is inevitable by conservative and surgical treatment, Surgeon should carried out the surgery after taking the consent of guardian to justify himself.[15]
Sushrut mentioned that before operation, surgeon should collect the following things beforehand: instruments, both sharp and blunt, caustics, cautery, fire, probes, leeches, horn, guard, cotton, gauze, suture, ligature material, medicinal leaves, bandages, honey, ghee, milk, oil, refreshing liquids, decoction, ointments, paste, fans, cold and hot water, utensil, and skilled attendant.[12]
Wise surgeon should find the exact size and shape of the foreign body, its exact location in the body should be known before hand, and appropriate instrument for its removal should be selected preoperatively.[16]
Patient should be completely nil by mouth or empty stomach before artificial or instrumental surgery, such as Udarrog (ascites), Arsha (hemorrhoid), Ashmari (renal calculi), Bhagandar (fistula-in-ano), and Mukhroga (diseases of mouth).[17]
Operative Ethics—Pradhankarma Sadvrutta
Break in the continuity of tissue is known as wound (Vrana). It should be protected from dangerous and invisible creatures. It is noticeable that the concept of invisible creature was there in those days even in the absence of microscope.[18]
Instruments that we use in surgery should be heated in fire to make the instrument sterile. So it can be concluded that concept of aseptic surgery was originated by Acharya Sushrut.[19]
When the surgeon who is not very acquainted with the handling of surgical instrument, uses them on the patients, accidents and other complications are liable to occur.[20]
He has also said that when Shastras (instrument) are made so sharp that it can slice the hair into two, when the different parts of the Shastras have been fixed properly, when the adjustments regarding the measurements have been done correctly, and when it has been held in the proper way, only then it should be used in surgical problems.[21]
Incision should be of sufficient length, having regular and uniformly cut edges, extensible having all the layers cleanly incised, should be independent and made swiftly in one stroke only are the qualities of good incision told.[22]
The incision should be oblique in eyebrows, cheeks, temporal region, forehead, eyelids, lips, gums, axilla, abdomen, and groin.[23]
Incision should be moon (circular) or like a half-moon (semicircular) in the upper and lower limb and above the anus and penis.[24]
Counter incisions should be given at some distance when one incision is not enough to clear the wound completely.[25]
Acharya said that blood is the origin of body, and body totally depends on it; hence, every attempt must be made to preserve it. In other words, blood is equivalent to life.[26]
After incision and removal of the cause of trouble and having made the wound bloodless, having fomented with heat or by applying warm ghee, and so on, having cauterized, if necessary, having applied a paste of ghee, and having bandaged, instructions should be given regarding its further management.[27]
Postoperative Ethics—Paschatkarma Sadvrutta
Acharya Sushrut explained in postoperative ethics. Vranitagaar, that is, ward for the operated case should be selected, keeping in mind that the place should be well planned, well equipped, and well arranged.[22]
The surgical bed should be of adequate dimensions and pleasant to look at, provided with mattresses and drawsheets, head end should face toward east, and it should be well guarded.[28]
Patient should be comfortable on bed and should be attended by caring and loving friends and relatives.[29]
After that Lepa (medicinal pastes) of Yashtimadhu and Ghrut should be applied over the wound, which should then be covered by a thick layer of pad and should be bandaged.[30] After this, the old bandage should be opened on the third day and reapplied exactly as before. There is no hurry to open it on the second day.[31]
Ethics and Importance of Experimental Surgery—Yogyakaran Sadvrutta
To obtain complete success in the aimed work, practice of similar operations beforehand is called Yoga and performance of such practice is called Yogya. Therefore, one who wants to become expert in surgery and other parasurgical procedures, should practice it experimentally on similar products.[8]
Quacks—Kuvaidya Vrutta
While defining Kuvaidya (quacks), Sushrut said that the Vaidya, who learns the Shastra (science of medicine) from Guru (teacher) and regularly takes the practical training (Yogya) and then practices medicine, is a real Vaidya (physician), others are Kuvaidya.[32]
Ethics in Emergency—Aatyayik Sadvrutta
Sushrut said that in emergency cases, Vaidya should not carry out the routine treatment, instead they should act as if their own home is on fire.[33]
| Conclusion | | |
Perception of surgical ethics was there in the time of Sushrut, maximum of which was mentioned by Sushrut in Sutrasthan of Sushrut Samhita. Sushrut described teaching and training methodology to produce highly skilled surgeon. He also mentioned that Suchita (cleanliness) of Sharir (body) and Mana (mind) of a surgeon while approaching a patient forms an utmost essential component.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Dorland D. Dorland’s Illustrated Medical Dictionary. 30th ed. Philadelphia, PA: WB Saunders;2000. p. 445.  |
| 2. | Shastri AD. Sutrasthan. 10/3. In: Sushrut Samhita. Vol I. Varanasi, India: Chaukhambha Sanskrit Sansthan;2013. p. 41. |
| 3. | Shastri AD. Sushrut Samhita. Vol. 2. Varanasi, India: Chaukhambha Sanskrit Sansthan;2013. p.41. |
| 4. | Shastri AD. Sutrasthan. 25/43–44. In: Sushrut Samhita. Vol I. Varanasi, India: Chaukhambha Sanskrit Sansthan;2013. p. 138. |
| 5. | Shastri AD. Sutrasthan. 5/10. In: Sushrut Samhita. Vol I. Varanasi, India: Chaukhambha Sanskrit Sansthan;2013. p. 24. |
| 6. | Shastri AD. Sharirthan. 5/51. In: Sushrut Samhita. Vol I. Varanasi, India: Chaukhambha Sanskrit Sansthan;2013. p. 64. |
| 7. | Shastri AD. Sutrasthan. 4/5. In: Sushrut Samhita. Vol I. Varanasi, India: Chaukhambha Sanskrit Sansthan;2013. p. 21. |
| 8. | Shastri AD. Sutrasthan. 4/7. In: Sushrut Samhita. Vol I. Varanasi, India: Chaukhambha Sanskrit Sansthan;2013. p. 21. |
| 9. | Shastri AD. Sutrasthan. 3/48. In: Sushrut Samhita. Vol I. Varanasi, India: Chaukhambha Sanskrit Sansthan;2013. p. 18-9. |
| 10. | Shastri AD. Sutrasthan. 3/49. In: Sushrut Samhita. Vol I. Varanasi, India: Chaukhambha Sanskrit Sansthan;2013. p. 18-9. |
| 11. | Shastri AD. Sutrasthan. 3/53. In: Sushrut Samhita. Vol I. Varanasi, India: Chaukhambha Sanskrit Sansthan;2013. p. 18-9. |
| 12. | Shastri AD. Sutrasthan. 5/3. In: Sushrut Samhita. Vol I. Varanasi, India: Chaukhambha Sanskrit Sansthan;2013. p. 23. |
| 13. | Shastri AD. Sutrasthan. 35/3. In: Sushrut Samhita. Vol I. Varanasi, India: Chaukhambha Sanskrit Sansthan;2013. p. 167. |
| 14. | Shastri AD. Sutrasthan. 39/10. In: Sushrut Samhita. Vol I. Varanasi, India: Chaukhambha Sanskrit Sansthan;2013. p. 192. |
| 15. | Shastri AD. Chikitsasthan. 7/29. In: SushrutSamhita. Vol I. Varanasi, India: Chaukhambha Sanskrit Sansthan;2013. p. 54. |
| 16. | Shastri AD. Sutrasthan. 27/23. In: Sushrut Samhita. Vol I. Varanasi, India: Chaukhambha Sanskrit Sansthan;2013. p. 146. |
| 17. | Shastri AD. Sutrasthan. 5/16. In: Sushrut Samhita. Vol I. Varanasi, India: Chaukhambha Sanskrit Sansthan;2013. p. 24. |
| 18. | Shastri AD. Uttartantra. 60/3. In: Sushrut Samhita. Vol I. Varanasi, India: Chaukhambha Sanskrit Sansthan;2013. p. 233. |
| 19. | Shastri AD. Chikitsasthan. 2/46. In: Sushrut Samhita. Vol I. Varanasi, India: Chaukhambha Sanskrit Sansthan;2013. p. 22. |
| 20. | Shastri AD. Sharirsthan. 8/21. In: Sushrut Samhita. Vol I. Varanasi, India: Chaukhambha Sanskrit Sansthan;2013. p. 91. |
| 21. | Shastri AD. Sutrasthan. 8/14. In: Sushrut Samhita. Vol I. Varanasi, India: Chaukhambha Sanskrit Sansthan;2013. p. 39. |
| 22. | Shastri AD. Sutrasthan. 19/3. In: Sushrut Samhita. Vol I. Varanasi, India: Chaukhambha Sanskrit Sansthan;2013. p. 102. |
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| 24. | Shastri AD. Sutrasthan. 19/14. In: Sushrut Samhita. Vol I. Varanasi, India: Chaukhambha Sanskrit Sansthan;2013. p. 104. |
| 25. | Shastri AD. Sutrasthan. 5/11. In: Sushrut Samhita. Vol I. Varanasi, India: Chaukhambha Sanskrit Sansthan; p.24. |
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| 27. | Shastri AD. Sutrasthan. 27/12. In: Sushrut Samhita. Vol I. Varanasi, India: Chaukhambha Sanskrit Sansthan;2013. p. 144. |
| 28. | Shastri AD. Sutrasthan. 19/5. In: Sushrut Samhita. Vol I. Varanasi, India: Chaukhambha Sanskrit Sansthan;2013. p. 103. |
| 29. | Shastri AD. Sutrasthan. 19/7. In: Sushrut Samhita. Vol I. Varanasi, India: Chaukhambha Sanskrit Sansthan;2013. p. 103. |
| 30. | Shastri AD. Sutrasthan. 5/17. In: Sushrut Samhita. Vol I. Varanasi, India: Chaukhambha Sanskrit Sansthan;2013. p. 26. |
| 31. | Shastri AD. Sutrasthan. 5/35. In: Sushrut Samhita. Vol I. Varanasi, India: Chaukhambha Sanskrit Sansthan;2013. p. 27. |
| 32. | Shastri AD. Sutrasthan. 5/40. In: Sushrut Samhita. Vol I. Varanasi, India: Chaukhambha Sanskrit Sansthan;2013. p. 26-7. |
| 33. | Shastri AD. Sutrasthan. 9/8. In: Sushrut Samhita. Vol I. Varanasi, India: Chaukhambha Sanskrit Sansthan;2013. p. 41. |
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