The Surgeon Before Surgery: Sushruta, the Indian Nose and the Birth of Plastic Surgery

A letter from Pune

In October 1794, The Gentleman's Magazine, one of the most widely read periodicals in Britain, published a short letter signed with the initials "B. L.". Accompanying it was an engraving of an Indian man with a strange, neat scar running down the middle of his forehead.

The man's name was Cowasjee. He had been a bullock-cart driver serving with the British army in the war against Tipu Sultan of Mysore. In 1792 he had been captured by Tipu's forces, and, as a punishment for working for the British, his nose and one of his hands had been cut off. For about a year he lived without a nose.

Then, according to the letter, he was treated near Pune by a man described as belonging to a caste of brick-makers. The operation was witnessed by two British surgeons of the East India Company in Bombay, Thomas Cruso and James Findlay. The Indian practitioner cut a flap of skin from Cowasjee's forehead, leaving it attached at the bridge of the nose so that its blood supply stayed intact. He twisted the flap down, shaped it over the wound to form a new nose, and held it in place with dressings and a binding of cloth. Within weeks, the flap had healed into place. Cowasjee had a nose again.

The letter described the method as long known in India, practised by people with no formal medical training in the European sense. To British readers, it was astonishing. European surgery at the time could cut off and cauterise. An Italian surgeon, Gaspare Tagliacozzi, had rebuilt noses with flaps of skin from the arm in the sixteenth century, but his method had long been abandoned and largely forgotten.

Twenty years later, in 1814, the London surgeon Joseph Constantine Carpue performed the "Indian method" on a British army officer who had lost his nose, and published an account in 1816. In Germany, Carl Ferdinand von Graefe adapted it soon after. The forehead flap became known in Western medical literature as the "Indian rhinoplasty", and it remains a foundation of reconstructive surgery today.

Behind that village practice in Maharashtra lay a much older tradition, recorded in one of the most remarkable medical texts of the ancient world: the Sushruta Samhita.

Who was Sushruta?

According to tradition, Sushruta was a physician and teacher who lived in Kashi (Varanasi) and learned the art of healing from Divodasa, a king of Kashi who was regarded as an incarnation of DhanvantariDhanvantari The physician of the gods, who rose from the churning of the ocean holding the nectar of immortality., the divine physician of the gods. The Sushruta Samhita, the "compendium of Sushruta", is presented as his teachings.

As with many ancient Indian texts, dating it is difficult. Many historians of medicine think its earliest layers may go back to the last centuries before the Common Era, and that the text was revised and expanded over a long period. The version that survives today includes later additions; one well-known tradition attributes a revision to a scholar named Nagarjuna. Fragments of related medical material appear in the Bower Manuscript, a birch-bark manuscript from around the fifth or sixth century CE discovered in Central Asia.

So we should not imagine Sushruta as a single genius who invented surgery in one lifetime. The Sushruta Samhita is better understood as the product of a living school of surgical practice, accumulated and refined over generations, and attributed to a revered founding teacher. That does not make it less impressive. It makes it the record of an entire tradition.

Alongside the Charaka SamhitaCharaka Samhita The other founding text of Ayurveda, on internal medicine rather than surgery., which focuses on internal medicine, the Sushruta Samhita is one of the two great foundational texts of Ayurveda. What sets it apart is its emphasis on shalya, surgery.

What the text actually contains

The Sushruta Samhita is a large work, organised into several sections that cover anatomy, diagnosis, treatment, toxicology, and much more. Its surgical content is genuinely extraordinary for an ancient text.

Eight kinds of surgical action

The text classifies surgical procedures into eight basic types:

That is a recognisably systematic way of thinking about what a surgeon does with the body, organised by the action rather than by the disease.

More than a hundred instruments

The text describes over a hundred surgical instruments, divided into blunt instruments (yantras) and sharp instruments (shastras). Many are named after the animals whose shape they resemble: forceps shaped like the beaks of herons, crows and other birds, for example. It specifies how the instruments should be made, how sharp their edges should be, and how they should be kept.

Learning on fruit and leather

One of the most modern-seeming features of the Sushruta Samhita is its approach to training. Students were not to practise first on patients. They were to practise incisions on gourds, cucumbers and other fruits; scraping on a piece of hide with the hair still on; puncturing on the veins of dead animals and on lotus stalks; suturing on cloth and soft leather; and bandaging on model limbs.

Today, surgical training increasingly relies on simulation: practising on models before touching a patient. The text was recommending the same principle some two thousand years ago.

Anatomy from the dead

The Sushruta Samhita also recognises that a surgeon must know the human body from the inside, and describes a method for studying a human corpse. The body was to be placed in a cage and left in a slow-moving stream for about a week, until the soft tissues loosened. The student would then gently scrape away layers with a brush made of grass or bark, observing the structures beneath, layer by layer, without cutting.

It is a clever method for a culture with strong taboos about cutting the dead. And it reflects a fundamental scientific principle: knowledge of the body should come from direct observation.

The nose that changed surgery

Now to the procedure that made the Sushruta Samhita famous worldwide.

In ancient and medieval India, cutting off the nose was a common punishment, inflicted for adultery and other offences, and sometimes on prisoners of war. The famous episode in the Ramayana where Lakshmana cuts off the nose of Shurpanakha reflects how familiar the act was. A disfigured nose carried enormous social stigma. That created a demand for reconstruction, and the surgeons of the Sushruta tradition answered it.

The Sushruta Samhita describes the procedure like this, in summary:

1. A leaf is cut to the size and shape of the missing part of the nose, to act as a pattern.

2. A flap of living skin, matching that pattern, is cut from the cheek, but left attached at one end so that it keeps its blood supply.

3. The edges of the nose are freshened, and the flap is turned and stitched into place.

4. Two small tubes are inserted into the new nostrils to keep them open while the tissue heals.

5. The wound is dressed with medicinal powders and bandaged.

6. Once the skin has united, if the new nose is too long or too short, the middle of the flap is divided and the nose adjusted.

Two features of that description are central to modern plastic surgery.

The pedicled flap. The key insight is that transplanted skin will die if it is cut off completely from its blood supply. By keeping the flap attached at a narrow "stalk", or pediclepedicle The stalk of living tissue that keeps a moved flap attached to its blood supply until it heals in., the surgeon keeps the tissue alive until it has grown new blood vessels in its new position. Pedicled flaps remain one of the fundamental tools of reconstructive surgery.

The template. Cutting a leaf pattern to match the defect is exactly what plastic surgeons still do, using paper, foil or digital planning, to measure the tissue needed before cutting.

There is one interesting difference between the ancient text and the 1794 operation. The Sushruta Samhita describes taking the flap from the cheek. The Pune practitioner used the forehead. Over the centuries, Indian practitioners appear to have refined the method, finding that the forehead provides more skin, a better match and a more reliable blood supply. The "Indian forehead flap" that Carpue introduced to Europe is the descendant of a tradition that kept evolving long after the text was written.

Other remarkable passages

The Sushruta Samhita describes much more than rhinoplasty.

• Cataract couching. The text describes a procedure for treating cataract by using a needle to push the clouded lens out of the line of sight. Couching was practised in many parts of the ancient world and survived in India into modern times. It could restore some vision, though with significant risks, and it has been replaced by modern cataract surgery.
• Earlobe repair. Stretched and torn earlobes, common among people who wore heavy earrings, could be repaired using flaps of skin from nearby tissue. The text describes many variations.
• Removal of bladder stones. The text describes cutting for bladder stones through the perineum, an operation also performed in ancient Greece and medieval Europe.
• Suturing the intestines. For injuries that opened the abdomen, the text describes cleaning and returning the intestines, and even mentions using the jaws of large ants to close small intestinal wounds: the ant is allowed to bite across the cut, and its body is then removed, leaving the head as a natural clip.
• Leeches. The text gives detailed guidance on using leeches (jalaukavacharana) to draw blood, including how to choose, keep and apply them.

That last item has an extraordinary modern sequel. In 2004, the US Food and Drug Administration cleared medicinal leeches as a medical device. They are used today in plastic and reconstructive surgery, particularly when a reattached finger or a skin flap becomes congested with blood that cannot drain away. The leech removes the excess blood and releases substances that stop it from clotting, buying time for the tissue to grow new veins. Two thousand years after the Sushruta Samhita described leeches, plastic surgeons, the heirs of the Indian nose operation, are using them again.

How the forehead flap works, then and now

To appreciate what the Indian surgeons achieved, it helps to understand the problem they solved, and how surgeons solve it today.

The skin is a living organ. It needs a constant supply of blood, delivered by small arteries and drained by veins. If you cut a piece of skin free and simply place it elsewhere, it may survive if it is very thin, because it can absorb nutrients from the bed beneath it until new blood vessels grow in. That is a skin graft. But a thin graft cannot rebuild a nose. A nose needs thickness, shape and structure.

The solution is the flap: a larger, thicker piece of tissue that stays connected to its own blood supply while it is moved. The forehead is ideal for this. Its skin is thick, it matches the colour and texture of the face well, and it is fed by arteries that run vertically up from above the eyes. A flap cut vertically from the forehead, with its base kept attached between the eyebrows, carries those arteries with it. The surgeon can then twist the flap downwards through about 180 degrees, shape it over the defect, and stitch it into place, while it continues to receive blood through its stalk.

That is exactly what the practitioner in Pune did for Cowasjee in 1794. Once the flap had grown new blood vessels from its new bed, typically after a few weeks, the stalk could be cut and the base trimmed neatly.

Modern plastic surgeons perform a refined version of the same operation, called the paramedian forehead flapparamedian forehead flap Today's standard forehead flap for rebuilding a nose, fed by one artery rising from the inner corner of the eyebrow., which is based on one of the two arteries that run up from the inner corner of each eyebrow. It is still one of the standard methods for reconstructing large defects of the nose, for example after removal of a skin cancer. Today's surgeons add cartilage grafts, usually from the ear or ribs, to give the new nose a firm framework, and a lining for the inside of the nostrils. They plan the flap with templates, just as the Sushruta Samhita advised with its leaf pattern. And, as in 1794, they usually divide the stalk a few weeks after the first operation.

Two thousand years separate the leaf template in the Sanskrit text from the foil template in a modern operating theatre. The principle has not changed: keep the tissue alive, measure before you cut, and rebuild the face from the person's own body.

Where the claims go too far

The Sushruta Samhita deserves the respect it receives. But in recent years, it has also attracted claims that go well beyond the evidence. They do Sushruta no favours, because they invite ridicule and distract from what the text genuinely achieved.

"Sushruta was the first surgeon in history." Surgery is much older than any text. Skulls with healed holes cut deliberately through the bone, a practice called trepanation, have been found in many parts of the world from the Neolithic period, thousands of years before Sushruta, including in India. In Egypt, the Edwin Smith PapyrusEdwin Smith Papyrus An Egyptian surgical text of about 1600 BCE, describing 48 injury cases in a strikingly modern order., a surgical text dating from around 1600 BCE, describes the examination and treatment of dozens of injuries in a strikingly systematic way. Ancient Greek and Chinese medicine also had surgical traditions. Sushruta is one of the great figures in the early history of surgery, and arguably the most important ancient source for reconstructive surgery. He was not the first surgeon.

"Ancient Indians performed head transplants, organ transplants and caesarean sections." The Sushruta Samhita does not describe organ transplants or head transplants. Such claims usually confuse skin flaps and grafts, which the text does describe, with transplanting organs from one body to another, which it does not. It does describe cutting a living child from a mother who has just died in labour, but not a caesarean section on a living mother. Stories from the Puranas, such as Ganesha receiving an elephant's head, are sacred myths, not surgical records.

"Sushruta invented anaesthesia." The text does recommend giving patients wine before surgery, and other traditions used herbs to dull pain. But nothing in it resembles the general anaesthesia that transformed surgery after the first public demonstrations of ether in Boston in 1846. Ancient surgery, everywhere in the world, was quick and painful.

"Ancient Indian surgery was as safe as modern surgery." It could not have been. Without an understanding of germs, which came only in the nineteenth century with the work of Louis Pasteur, Joseph Lister and others, infection was a constant danger. The Sushruta Samhita does emphasise cleanliness, fumigation of the operating room, and clean dressings, which would have helped. But we have no way of knowing its success rates, and they would certainly have been far lower than those of a modern hospital.

None of these corrections diminishes Sushruta. They place him where he belongs: among the great early pioneers of surgical knowledge, with a specific, documented contribution that changed medicine.

How an Indian village craft reached London

Perhaps the most moving part of this story is how the knowledge survived.

By the eighteenth century, the formal Sanskrit surgical tradition had largely faded. But the nose-reconstruction technique had not disappeared. It had passed into the hands of practitioners outside the learned elite, families and communities who handed the skill down from generation to generation, as craftspeople do. The man who rebuilt Cowasjee's nose was not a Brahmin physician reading Sanskrit. He was, according to the account, a member of a brick-making community, practising a skill learned from his elders.

That is how knowledge often survives: not in grand libraries, but in the hands of ordinary people who keep doing something because it works. A technique first written down in a Sanskrit text was preserved in practice by artisans, observed by British surgeons, printed in a London magazine, adopted in European hospitals, and eventually built into the foundations of a medical specialty that now rebuilds the faces of accident victims, cancer patients and wounded soldiers all over the world.

In 2018, a marble statue of Sushruta was installed at the Royal Australasian College of Surgeons in Melbourne. Many plastic surgeons around the world know his name and the story of the Indian forehead flap.

The claims, checked

Honour that does not need inflating

The story of Sushruta and the Indian nose is a rare and precious thing in this journal: an ancient Indian claim that the evidence largely supports.

A Sanskrit text described a sophisticated method of rebuilding a nose with living skin, based on a principle that remains central to surgery today. The technique survived in India for centuries, in the hands of practitioners who might never have read the text. It was carried to Europe by British observers and became one of the foundations of modern plastic surgery. All of that is documented. None of it needs exaggerating.

The irony is that the inflated claims, of transplants, of anaesthesia, of the "first surgeon", actually make it harder for the world to take the true story seriously. A sceptic who hears that ancient Indians performed head transplants will dismiss everything else. A sceptic who hears that a brick-maker in Pune rebuilt a soldier's nose in 1794 using a technique described in a Sanskrit text perhaps two thousand years old, and that surgeons in London learned from him, will be impressed, and rightly so.

That is the lesson Sushruta teaches beyond surgery. The truth, carefully told, is always the strongest case. It does not need a bigger nose than it has.

Further reading

• The Sushruta Samhita, translated by Kaviraj Kunja Lal Bhishagratna (1907-1916)
• "B. L.", letter on the operation on Cowasjee, The Gentleman's Magazine (October 1794)
• J. C. Carpue, An Account of Two Successful Operations for Restoring a Lost Nose from the Integuments of the Forehead (1816)
• Dominik Wujastyk, The Roots of Ayurveda: Selections from Sanskrit Medical Writings (2003)
• Kenneth G. Zysk, Asceticism and Healing in Ancient India: Medicine in the Buddhist Monastery (1991)
• US Food and Drug Administration, clearance of medicinal leeches as a medical device (2004)