HISTORY OF INDIAN PLASTIC SURGERY

Compiled by : Prof. J.L. Gupta, Past President APSI & Dr. Rajeev B. Ahuja , Hony. Secretary-APSI

Just as the Sun rises in the East, the science of plastic surgery first dawned in the ancient Indian civilization. In India, from the beginning of recorded history, offenders or sinners were punished with mutilation or severance of nose, ears or parts of limbs. Indian mythology and history are replete with stories of Surpanakha and Nakatapore i.e. 'city without nose'. Moreover, in India nose is considered to be the organ of respect and reputation, hence, plastic surgical procedures to correct these deformities was a necessity.

The first detailed description of plastic surgical procedures is found in the clinical text on Indian surgery, the 'Sushruta Samhita' (circa 600 B.C.). Atharva Veda, the root of Ayurveda , the classical text of Indian medical knowledge includes two seminal texts, Charaka Samhita on medicinal aspects and Sushruta Samhita which incorporates details of surgical tools and operative techniques. Sushruta wrote this treatise based on the lectures of his teacher, the famous surgeon king, Devadas ('incarnation of Dhanwantari , the divine physician). In fourth century A.D. Vagbhat , an Indian physician recounted the plastic surgical procedures with more details than provided in Sushruta Samhita. In his book , 'Ashtanga Hridyans Samhita' he credits the techniques to Maharishi Atreya. It is interesting to find mention of plastic surgical procedures such as rhinoplasty, otoplasty, tissue grafting, organ transplants, transfer of embryo, cross-grafting of head and re-attachment of limbs etc. in these ancient Indian Medical Treatises and Puranic Literature.

This golden era of Hindu Surgery began its gradual decline from the time of Buddha (562- 472 B.C.). Buddhist scripture Mahavagga Jataka enforced strict prohibition on surgeons and Manusmriti prescribed special rituals for purification of surgeons. Contemporary teaching that time was basically medicinal i.e. Ayurveda, which forbade surgery, as contact with blood and pus was considered polluting. Hence, during this period, these great surgical skills were delegated to lower castes like 'Koomars' or potters who were known for their manual dexterity. They kept alive this valuable knowledge and passed it from father to son as a family secret. Some of these families were identified in the later half of eighteenth century. Marathas of Pune , Kangharias of Kangra (Himachal Pradesh) and some families in Nepal were practicing ancient Indian surgical skills; most notable amongst them being midline forehead rhinoplasty. In Kangra, forehead rhinoplasty had been practiced for centuries by a family of Hakim nose surgeons called 'Kanghiaras' . They had been operating at Kangra since the time of Raja Sansar Chand (1440 A.D.) and had also obtained certification from Mughal kings. Hakim Dina Nath Kanghiara was the last surviving descendent of the family who is known to have performed this operation. Details of their surgical skill appeared in Punjab Medical Journal in 1967. Still later, Dr. Tribhovandas Motichand Shah, the then CMO of Junagadh is said to have performed 400 rhinoplasties by forehead flap.

In fact India and Egypt are considered as the fountain-heads from which the stream of knowledge flowed to the middle east, eventually to reach Mediterranean civilization; the Greeks and the Romans. The ancient Indian medical knowledge was carried into Greece and Arabia by Buddhist Missionaries. Further still, avenues of trade were setup between Greece and India following the conquests of Alexander 'The Great'. Arabs played an important role in transmitting the surgical knowledge to the West. The Persian hospital at Gondi-Sapor (6th -10th century A.D. ) was a great centre of learning in that era which permitted amalgamation of Hindu, Greek and Arab schools of thought. Here, the Sushruta Samhita was translated into Arabic, and later into Latin. Arabic physicians of that time, Rhazes and Aviceruna often referred to the teachings of Sushruta and Paulus Aegina. Paulus Aegina was a 7th century Greek physician who was responsible for the integration of Indian and Western surgical knowledge, and he summarized it in a seven volume compendium. Further down the time line, Aulus Cornelius Celsus (25 B.C.) propagated this science to Rome in his book 'De Re Medica'. During 525 A.D. orthodoxy of the church started rising and the enthusiasm towards surgery declined. Surgical skills were now reared in hands of people of lower status like barbers, similar to what had happened in India centuries ago. Sushruta Samhita was translated into English by Kaviraj Atrideo Gupta Vidyalankar Bishangar (1950 ) and Kaviraj Kunjalal Bhishagranta (1963).

Despite these hurdles, reconstructive operations of nose and face received an impetus in the European countries during 19th century.The German, French and English surgeons were introduced to the older Indian method. During that period, certain German scholars who studied the original text in Sanskrit, British surgeons and French travelers, who saw for themselves the rhinoplasty operations performed in India, revealed the wonders and practical possibilities of this speciality to the Western world.

It was, however, the discovery of anaesthesia (Mortin, Long and Wells) and anti-sepsis (Lord Lister ) which revolutionised the practice of surgery and made it painless and infection free. Modern plastic surgery in India started after World War II. During the war, there were couple of British Maxillo-facial Surgery Units and a special mention was made about them by Mr. Tom Gibson ( Canniesburn Hospital ) at Bangalore and by Mr. E.W. Peet at Pune, during their visits to India. This kindled the interest in Plastic surgery among a few young Indian surgeons working then with the armed forces as "temporary commissioned officers". After the war, two of them i.e. Dr. C. Balakrishnan and Dr. R.N.Sinha specialised in Plastic Surgery, while Major Sukh continued his interest in the speciality as a pioneer in the field of plastic surgery at the Armed Forces Medical College and Hospital, Pune.

There was no existence of plastic surgery as a recognised speciality in the country. While in training at Stoke Mandeville Hospital, U.K., Dr. C. Balakrishnan sent a memorandum to the Director General of Health Services, New Delhi, proposing to start and develop a Department of Plastic and Maxillo-facial Surgery, because there was a crying need for at least one such department in the country. After great persuation, he was offered the post of lecturer and surgeon at Medical College and Hospital , Nagpur (at that time known as the Central Provinces of Madhya Pradesh and Bihar State). He accepted the offer and started to develop a department of plastic and maxillo-facial Surgery. Dr. R.N.Sinha, who was trained under Prof. Kilner , on his return to Medical College, Patna (Bihar State) made pioneering efforts to educate surgical colleagues, State and Central Government and the Medical Council of India about the need to develop plastic surgery as a speciality. He wrote numerous articles in scientific journals and lay press to drive home the point. This indeed was a great task since there were no books or literature available to read, learn from and guide about the new speciality. During these days even minor progress was very difficult, because the development of specialities was generally frowned upon and frankly discouraged by general surgeons. Slowly even the patients started realising that a person who concentrates in one field does much better than one who is "jack of all trades and master of none. It required all the tenacity and dedication of a handful of pioneer Indian plastic surgeons, who made plastic surgery their career, to go over the initial difficulties. For almost 8 to 10 years, these pioneers at Nagpur, Patna, and later at Lucknow, Bombay and Calcutta struggled hard for their existence and worked as sections in the department of general surgery.

Dr.N.H.Antia, after his post-graduate training in plastic surgery from U.K. started working in a private hospital in Pune and was also engaged in rehabilitative surgery at the 'Kandhwa Leprosy Centre' outside the city. He carried drums with sterilized linen and instruments from Pune to the leprosy centre. Dr. Antia worked here in a makeshift O.T. on absolutely voluntary and honorary basis inspite of considerable hardship. His pioneering work in leprosy was rewarded by an invitation from England to deliver the Hunterian Lecture at the Royal College of Surgeons, London. In 1955,

Sir B.K. Rank visited India, from Australia, on a goodwill mission under the Colombo Plan to advise the Government of India and his own Government about the possibilities of developing plastic surgery in India. He spent two weeks in India and recommended the development of a Centre of Excellence at Nagpur under the dynamic leadership of Dr. Balakrishnan. This was to be aided upto 50% under the Colombo Plan and the rest to be granted by Central and State Governments. Unfortunately, it never materialized. However, the first and the only independent Department of Plastic Surgery in the country was finally created at the M.C.Hospital, Nagpur, in 1958.

By 1955, there were about four to five plastic surgeons devoting their full time to this speciality and there was a desire to form an Association. Thus, in the Annual General Body Meeting of A.S.I. held in December, 1956 at Indore, Dr. R.N.Sinha moved a resolution to this effect. A sub-committee was formed with Dr. C.P.V. Menon of Madras as its Chairman and Dr. R.N.Sinha as the Convenor to frame Bye-laws and Regulations for an Association of Plastic Surgeons of India - as a Section of Association of Surgeons of India.

In the year 1957 considerable interest was created in Maharashtra following the visit of Sir Harold Gillies. He was pleasantly surprised to see deformities being treated by tube pedicles and other modern techniques of plastic surgery. He applauded the excellent work that Major Sukh was doing in the field of Rehabilitative Plastic Surgery at the Armed Forces Medical College, Pune. It was not only an eye-opener for all., but a surprise to Dr. Gillies himself. Many war casualties had extensive stay in his unit for such procedures of rehabilitation. Sir Harold Gillies also demonstrated various operations and techniques at Kandhwa Leprosy Centre, where Dr.N.H.Antia was working. Dr. Gillies, as the founder of modern plastic surgery was keen to propogate knowledge in this speciality in one of the most populous countries of the world. He visited and lectured at several centres in the country including Nagpur, Calcutta, Delhi, Patna and Jaipur . At Nagpur, in December 1957, he inaugurated the Association of Plastic Surgeons in India - as a section of A.S.I. The Association elected the following office bearers:

In December 1958, at Lucknow, the Association elected : -

In December 1960, at Pune, the following office bearers were elected :-

A Burns and Plastic Surgery Unit was established in 1961 at K.E.M. Hospital, Bombay, by Dr. Charles Pinto. Mr.E.W. Peet of Oxford was a regular visitor to this unit.

Dr. R.L.Maneksha after his return from abroad in early fifties continued doing Plastic Surgery under the Department of General Surgery. Later he was responsible for establishing the Unit of Plastic Surgery at G.T.Hospital, Bombay, in early sixties.

Dr. J.L. Gupta after 5 years of post-graduate training in various British centres of Plastic, Maxillo-facial, Burns and Hand surgery, was interviewed in India House, London, and selected for the post of Reader in the Department of Plastic Surgery at Medical College, Nagpur, which he joined in January 1961. Dr. Gupta was greatly impressed by Prof. C. Balakrishnan who had completely adapted himself to Indian conditions while maintaining international standards.

In December,1961 at Baroda, Dr.R.J.Maneksha and Dr.J.L.Gupta were added to the Council of Members. The first summer conference of the Association was held at Nagpur in 1964. The most outstanding feature of the conference was the brilliant presentation on the classification of cleft lip and palate by Prof. C. Balakrishnan; now known throughout the country as Nagpur Classification.

The first batch of post-graduate students trained in our country appeared for their examination from Nagpur and Patna Universities in 1962 and 1963 respectively. Dr. J.L. Gupta was the first external examiner at Patna.

In 1963, the Government decided to start a Department of Burns, Plastic and Maxillo-facial Surgery at Safdarjung Hospital in Delhi. Dr. J.L. Gupta had the honour of starting and developing this unit and by shear hard work and dedication it became a major unit of Plastic Surgery in India in a very short time. It still is the largest burn centre in the country.

In 1964, first Post-graduate Medical Education Conference was convened by the Medical Council of India under the Chairmanship of the then Union Minister of Health Dr. Sushila Nayyar at Delhi. She had convened this meeting to standardize post-graduate curriculum of different specialities which was then to be carefully supervised by the Medical Council of India. To draft the syllabus for Plastic Surgery the following attended the Post Graduate Medical Education Conference.

Dr.R.L.Manchanda and Dr.R.K.Keshwani from Patiala joined as Observers.

This Conference was a hallmark in laying down guidelines for physical standards and criteria, the teaching requirements, the course and curriculum leading to the degree of M.Ch. in Plastic Surgery in India.

The Conference of A.S.I. due in December 1964 was postponed due to Indo-Pakistan conflict and was later held in Delhi, in March 1965. The Association elected the following office bearers.

Then in 1966 at Manipal, the Association elected the following.

Dr.R.N.Sharma represented our Association at the International meeting held at Rome in 1967. Thus , APSI joined the International Confederation of Plastic Surgeons.

By December 1967, the Association had grown to about 66 members (including 37 full members). At this time the Association elected the following.

By 1968, we had 11 plastic surgery centres in the country at Nagpur, Patna, Lucknow, Bombay, Pune, Delhi, Chandigarh, Patiala, Madras, Madurai and Calcutta. From 1968 -1974 the following were elected as Presidents of the Association, Dr. C. Pinto, Dr. R.L. Maneksha, Brig. R. Ganguly, and Dr. J.L. Gupta.

In the last three decades, there has been tremendous growth of Plastic Surgery. The number of teaching centres increased and the Association established several travelling fellowships for training within and outside the country. A few specialized centres of excellence for management of burns, hand, micro-vascular surgery, cranio-facial surgery and aesthetic surgery also developed by dint of hard work, and special interests in different parts of the country. The Indian Journal of Plastic Surgery started in 1981 to bring together all the professionals involved to disseminate and advance their knowledge.

The following were Presidents and Secretaries of the Association after 1974.

The following universities/ institutions currently provide Post Doctoral Courses in Plastic Surgery in India which are also approved by the Medical Council of India .

Bibliography :

1. The Story of Plastic Surgery : Dr.R.N.Sinha PP 173 -185 Patna Medical Journal July, 1950.
2. Postgraduate Medical Education Conference, Delhi November,1964 Medical Council of India.
3. A Short History of Plastic Surgery Section. Dr.R.N.Sinha and Dr.C.Pinto : December 1966.
4. Progress of Plastic Surgery in India : Dr.R.N.Sinha PP 6639-6641 - Journal of Indian Medical Profession : Nov.1968
5. A Short History of Plastic Surgery Section - Dr.R.N.Sharma April,1991.
6. Personal Communication - Dr.N.H.Antia and Dr. M.Mukhopadhya from Patna : September,1991.
7. Progress of Plastic Surgery in India - Dr.J.L.Gupta Bombay Hospital Journal - Vol. 35 No. 1 January,1993.
8. The story of plastic surgery - J.S.Davis . Ann of surg 112:641, 1941.
9. History of plastic surgery -S.C.Almast .In Textbook of Plastic Surgery in Tropics : R.N.Sinha ,J.L.Gupta , A.C.Ganguly (Eds).Orient Longman Ltd. New Delhi ,1976 pp 3-20.
10. Rhinoplasty in 'Kangra'. S.C.Almast . Punjab Medical Journal 16:287,1967.
11. Sushruta Samhita . Sushruta . English translation by Kaviraj Kunjalal Bhishagratna in 3 vol. The Chowkamba Sanskrit Series office,Varanasi,1963.
12. History of Rhinoplasty : Dr. Sameek Bhattacharya, Dr. Prabhat Shrivastava, Proceedings of Rhinoplasty-2000, Instructional Course, 31st March-2nd April, 2000, p29-34, Published by Department of Burns & Plastic Surgery, Lok Nayak Hospital and Maulana Azad Medical College, New Delhi.

If the reader wishes to add / update information about this article please correspond with Dr. Rajeev Ahuja , Secretary, APSI at rbahuja@vsnl.com

(DR.J.L.GUPTA)
Consultant in Burns, Plastic
and Maxillo-facial Surgery
Formerly Prof. and Head,
Department of Plastic Surgery
Safdurjang Hospital,
New Delhi.