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Susruta and Ancient Indian Neurosurgery
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Susruta and Ancient Indian Neurosurgery Anirban D. Banerjee, Haim Ezer, Anil Nanda
The Golden Age of surgery in ancient India rests largely on the shoulders of Susruta, who lived sometime between 700 and 600 B.C. Susruta practiced and propagated the art of surgery at the University of Benares in that ancient city, located on the banks of the holy Ganges. His monumental treatise on surgery, Susruta Samhita, glorified him as the Father of Indian Surgery. He was the first to systematize “surgery” into two distinct “fields,” including, in essence, what we know today as the field of neurosurgery. The present article elucidates the contributions of this great surgeon from a neurosurgeon’s perspective.
INTRODUCTION Let’s go back in time about 3 millennia. A warrior, with his skull fractured by an axe or a club in the heartland of India, is laid on a large stone block. None of the basic supports we have today exist: no anesthesia as we know it, no antibiotics, no advanced metal instruments, no sterilization of tools, and no proper illumination. The cutting tools are carved out of traditional metals and stone and chipped to produce sharp edges. Perhaps there are some herbal leaves that can be chewed or maybe a potion of wine to effect a little indifference to pain. The wounded scalp is reflected back, and the surgeon begins with the sharpened “tool,” sawing it back and forth, making grooves deep into the skull. If the wound is such that the piece to be removed is polygonal, the grooves overlap at the corners, and when they are deep enough, the piece or pieces are lifted out. Now the surgeon replaces the flap, using ants as staple-sutures. Key words 䡲 Ancient 䡲 Indian 䡲 Neurosurgery 䡲 Susruta From the Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA To whom correspondence should be addressed: Anil Nanda, M.D., F.A.C.S. [E-mail: [email protected]] Citation: World Neurosurg. (2011) 75, 2:320-323. DOI: 10.1016/j.wneu.2010.09.007 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2011 Elsevier Inc. All rights reserved.
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Without antibiotics, the chances for infection are great; the patient may live, or he may die. The “wise” surgeon hopes for the best. The previous description is the typical backdrop that reflects the turbulence surrounding the life and times of the first scientist-surgeon of India: Susruta. Despite all odds, he marched on—unimpressed by his successes and undaunted by his failures. “When the path did not exist, he made one” (16).
disciple of Dhanwantari, and instructs him on the science of surgery. Another version associates Susruta’s tutelage to Divodasa, a physician king of Varanasi (1, 5). This school of thought creates more confusion, however, because some authorities consider Divodasa and Dhanwantari to be the same entity. With ancient India, there is certainty in the existence of the sacred texts associated with Atreya, the world’s oldest record of medical practice (22). Uncertainty prevails, however, concerning whether the “samhita” attributed to Susruta was from a historical figure or from different physicians using a prominent name to give credence to their views (6, 11). The various listed time points related to Susruta include 1000 B.C. (17), 800 – 600 B.C. (19), 600 B.C. (15), 600 –200 B.C. (1), 200 B.C. (8), 1–100 A.D. (18), and 500 A.D. (7). Resolution of these uncertainties has been achieved to a certain extent by the following observations:
y Several Vedic hymns were dedicated to Susruta (10).
REALITY OR MYTH? The very existence of “Susruta” (the name literally means “the one who is well heard”), similar to his times, is shrouded in mythology and controversy. Bass, a German historian, asserted that Susruta had actually been Hippocrates; the name, he justified, had been confounded with Socrates in the Indian tenets and finally transmitted as “Susruta.” Bass based his hypothesis on the fact that Susruta’s birthplace was given as Kasi, an old name for Benares. That was, to him, an obvious distortion of the name of the Greek island of Kos, where Hippocrates was born. Pondering on this apparently distorted version, Gordon (8) commented, “How one clever enough to read Hippocrates in the original and reproduce it in his own language could mistake the name of Socrates for Hippocrates surpasses one’s imagination.” Some say that Dhanwantari, the physician to the gods, descends to earth to minister to the misery and disease of mankind while extolling them in the science of life (10). He subsequently reaches Benares and meets Susruta as the son of Rishi Vishvamitra, a
y Susruta’s description of the human skeleton (“300 bones”) was very similar to the one in the Atreya samhita (10).
y Hoernle’s critical analysis of the ancient Bower Manuscript (9) showed Susruta was a historical figure during 600 B.C. The eminent anatomist and medical historian Keswani noted the various “absurd and amusing theories” that denied the existence of Susruta and wrote (5): “Considering all the evidence available today, one comes to the conclusion that ‘the lowest limit of Sushruta’s death is fixed as the sixth and seventh Century B.C., this being the date of the Satapatha Brahmana, while nothing can be said about the upper limit.” Around 700 – 600 B.C. has been selected for the era of Susruta.
MEDICAL TRAINING Apart from the mythologic impression of Susruta being the son of Saint Vishwamitra, little is known about his ancestors. Susruta is
WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2010.09.007
PEER-REVIEW REPORTS ANIRBAN D. BANERJEE ET AL.
thought to have begun his medical education under Divodasa Dhanvantari, the king of Benares. Divodasa, in his “gurukul,” teaches him the nature of the “purusa” (person) who is afflicted with disease and who is to be treated: the nature of disease that causes pain and its eradication, the types of food, the dravyas, and the time factor. He also asks his students to consult as many other disciplines as necessary to attain sound knowledge in one’s own subject. Among the “alpha-omega-alpha” pupils of Divodasa were Aupadhanava, Aurabhra, Paushkalavata, and Susruta (21); however, Susruta documented and delivered the first focused and stratified treatise on “Salyatantra” (“Salya”—arrow of the enemy; “tantra”—man oeuvre), or surgery.
AS A SURGEON The origin of surgery in India can be traced back to the earliest times, probably back to the Indus Civilization. The Rig-Veda mentions many surgical feats of the celestial twin medical experts, the Asvins. Among the eight divisions of medical knowledge (ayurveda), surgery was considered the first and the most important branch. Surgery held a great deal of importance in ancient India, mainly owing to large-scale warfare, as myriad mutilating injuries inflicted on the apparently never-ending battlefields clamored for effective and expeditious management. Despite an existent knowledge of pharmacopoeia, there was a distinct paucity of a systematic approach to surgical interventions. Surgery in pre-medieval India reached its highest point under Susruta in Benares. He is believed to be the first to bring together the scattered knowledge of surgery and propound a systematic stratification of the science and art of surgery in his “compendium” (“samhita” in Sanskrit): Susruta Samhita. It remains difficult, however, to be absolutely certain whether the Susruta Samhita was composed by Susruta alone or the original author and a number of his subsequent disciples over the next few generations. The entire Susruta Samhita is a complete work on medicine with special attention to surgery, broadly divided into two major fields of surgery: Salya (major surgery) and Salakya (supraclavicular surgeries) tantras. The compendium details about 300 kinds of operations that call for 42 different surgical processes and 121 different types of instruments. The text is long—more than 1700 pages in
SUSRUTA AND ANCIENT INDIAN NEUROSURGERY
English translation (2-4). The Susruta Samhita is in two parts, the Purva-tantra (the main book) and the Uttara-tantra (an addendum). The Purva-tantra comprises 120 chapters arranged in five sections, as follows:
y Sutra Sthana: fundamental principles y Nidana Sthana: etiology and clinical features
y Sarira Sthana: anatomy and physiology y Cikitsa Sthana: therapeutics y Kalpa Sthana: toxicology The entire Uttara-tantra has been called Aupadravika because many of the complications of surgical procedures are briefly described here. Susruta emphasizes that removal of foreign bodies is fraught with certain complications if the seat of the Salya be a “marma” (eloquent area). These two parts together encompass, apart from Salya and Salakya, the other specialties of medicine, including pediatrics, geriatrics, toxicology, aphrodisiacs, and psychiatry. Susruta emphasizes in his text that unless one possesses adequate knowledge of relevant allied branches, one cannot attain proficiency in one’s own subject of study. The succinct style and the overall superiority of the Susruta Samhita led to the minimization of other preceding or contemporary treatises.
CONTRIBUTIONS TO NEUROSURGERY AND NEUROSCIENCE Neurosurgery Neurosurgery in ancient India takes its roots from the mythologic description of transplantation of the head (exemplified by the implantation of head of an elephant on Lord Ganesha) in ayurveda. Trephination and the removal of an intracranial mass by Jivaka (surgeon to Lord Buddha) have been documented also (12, 19). The master surgeon Susruta is said have included elementary neurosurgery in his accomplishments: “Ten nerves maintain the functions of the body by carrying impulses of sound, touch, vision, taste, smell, respiration, sighing, yawning, hunger, laughing, speech, and crying . . .” “A pair of nerve each responds to sound, touch, vision, taste, and smell.”
WORLD NEUROSURGERY 75 [2]: 320-323, FEBRUARY 2011
“Two nerves lower down at the back of ear (vidhura) which if cut produce deafness; a pair of nerves inside the two nostrils which if cut cause anosmia; a pair of nerves below the end of the eyebrow which if cut causes blindness.”—Susruta Samhita. Susruta considered the head as the center of all functions. Through his immaculate dissections, he vividly described the cranial nerves including the optic and vestibulocochlear nerves in cadavers and hypothesized their physiologic importance. Susruta also attaches importance to neuroembryology in the Sarira-sthana (21) section: “In the fifth month the fetus is endowed with the mind and wakes up from the sleep of his subconscious existence. In the sixth month cognition (Buddhi) comes in. In the seventh month all the limbs and members of its body are markedly developed. Sanuka says that probably the head of the fetus is the first developed since head is the only organ that makes the functions of all other organs possible.” In the Uttara-tantra section (3), Susruta discusses his experiences with supraclavicular surgeries or salakya-tantra. Apart from extensive discussions of diseases of eyes, ear, and nose, he dwells on surgical procedures involving the head and pertaining to the cranial structures, mainly dealing with warfare injuries, including trephining, excising, probing, puncturing, suturing, and evacuating “collected” fluids. The 22nd chapter of the Uttaratantra also describes a condition that could well be post-traumatic cerebrospinal rhinorrhea: “Kshavathu is said to be of two kinds (1) Doshaja and (2) traumatic.” Susruta’s method of treating spinal injuries reflects his great knowledge on the subject (20). On the treatment of cervical spine dislocation, he instructed to grasp the head at the neck along with the angle of the jaw and lift it up.
Susruta’s Instruments Susruta describes a variety of blunt and sharp instruments for distinct surgical procedures, including cranial and spinal surgeries, and adds that a surgeon, by his own experience and intelligence, may invent new instruments to facilitate the surgical procedures. He claims, however, that “the hand” is the most important and the best instrument. The blunt instruments are meant for removal of foreign
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bodies, for sucking the fluids, for facilitating the various surgical procedures, and for visualizing. The double-armed axial instruments are called swastika-yantras, resembling the modern forceps. Susruta’s classification and description became the basis for the development of instruments. He was apparently the first person to introduce the diagnostic instruments and their principles, which were modified later with the introduction of optic support (2-4).
Neurology Susruta terms the various disorders (and related remedies) of nervous system as Shiroroga, relating them to Vatavyadhi (disorders of Vayu) (3). He elaborates on akshepaka (convulsions), pakshavadha (hemiplegia), ardita (total paralysis), danda patanka (Parkinson disease), manya sthamba (stiff neck), jihavasthamba (paralysis of tongue), gridarasi (sciatica), murcha (fainting), dhanushsthamba (tetanus), and apasmara (epilepsy) in the related chapters of his treatise.
Psychiatry Susruta places great importance on the necessity of a healthy mind for a prosperous life. In the Sutra-sthana section of Purva-tantra, Susruta describes in great detail the diseases pertaining to manasa (mental health). Excessive anger, grief, fears, joy, despondency, envy, misery, pride, greed, lust, desire, and malice are included within the category of manasa disorders. A plant called “soma,” which is described in the early texts but has never been clearly identified, was recommended as a treatment for rejuvenating body and mind. Susruta explains the need of all living creatures to sleep and to dream as a function of two principles of the mind that give glimpses of previous existences or warn of future ill health. When both principles are weakened, coma results (2-4).
CONTRIBUTIONS TO THE SCIENCE OF SURGERY Susruta describes various types of surgical procedures: chedana (excision), bhedana (incision), lekhana (scraping), scooping, vyadhana (puncturing with special instrument), esana (probing), sravana (blood-letting), and svana (suturing) (2-4). Some salient presurgical procedures, such as cauterization by Ksaras
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SUSRUTA AND ANCIENT INDIAN NEUROSURGERY
(alkaline substances) or Agni and application of leeches, were being practiced by Susruta. Thermal cauterization for therapeutic purposes has been advocated by heating various substances and applying them at the desired sites. Susruta points out that hemorrhage can be arrested by apposition of the cut edges with stitches, application of styptic decoctions, or cauterization with chemicals or heat (2-4). He advocates the use of wine as an anesthetic. Although the use of henbane (Cannabis indica) and of Sammohini and Sanjivani are reported at a later period, Susruta might be considered as a pioneer in this regard. The progress of surgery and its development is closely associated with the great wars of the past. A major contribution of Susruta is in the subject of trauma and critical care. He speaks of six varieties of accidental injuries encompassing almost all parts of the body. Susruta also classifies the bones and their reaction to injuries, varieties of dislocation of joints (sandhimukta), and fractures of the shaft (kanda-bhagna). He classifies the 6 types of dislocations and 12 varieties of fractures. He propounds the principles of fracture treatment, as follows: traction, manipulation, appositions, and stabilization, including measures of rehabilitation. Susruta illustrates the vrana or injury as involving the breakdown of body components, such as skin, flesh, blood vessels, sinews, bones, joints, and internal organs. Classically, vrana, the wound, is the ultimate explosion of the underlying pathologic structure. “The sixth stage of a continuous process, which starts with sotha (inflammation). In the first stage, the ulcer is unclean and hence called a dusta-vrana; following treatment it becomes a suddha-vrana; there is a subsequent attempt at healing and is called ruhyamana-vrana and when the ulcer is completely healed, it is a rudha-vrana.”—Susruta Samhita. Fourteen types of bandaging capable of covering almost all the regions of the body are described for the practice of the student on dummies. Susruta has elucidated the four degrees of accidental burns, the effects of heatstroke and sunstroke, the effect of frostbite from excessive cold, and the effect of lightning, which he calls vidyut-dagdha (2-4). Susruta presents the basic principles of plastic surgery: accuracy, precision, economy, hemostasis, and perfection. He advocates proper physiotherapy before the operation and describes various methods or different types of defects, such as (i) release of the skin for covering small defects, (ii) rota-
tion of the flaps to make up for the partial loss, and (iii) pedicle flaps for covering complete loss of skin from an area. He mentions various methods including sliding graft, rotation graft, and pedicle graft. Nasal repair or rhinoplasty has been described in greater detail, which to this day has stood the test of time and is mentioned as the Indian method of rhinoplasty in textbooks of plastic surgery. The procedure was observed in India by a British surgeon in 1793 and published in London the following year, changing the course of plastic surgery in Europe (13). Susruta was very familiar with the signs and symptoms, methods of extraction, and operative complications of various types of urinary stones. In addition, he describes surgery of intestinal obstruction (baddhagudodara), perforated intestines (chidrodara), and accidental injuries to the abdomen (assaya-bhinna). The Susruta Samhita describes methods of management of hemorrhoids and fistulas, describing different types of incision to remove different fistulous tracts (langalaka, ardhalangalaka, sarvabhadra, candraadha [curved] and kharjurapatraka [serrated]), analogous to a modern general surgery practice. Susruta also describes various types of cataracts and the procedure of couching. It is also stated that he contributed to the introduction and practice of the technique of cesarean section (5, 6, 22). In the area of exercise physiology, Susruta stressed the importance of regular and disciplined exercise in maintaining equilibrium among the three “humors” of life to prevent and expedite the cure of various diseases (23). Sausruts Another probable “first” that can be credited to Susruta is his establishment of a structured training program, spanning 6 years, for his disciples (sausruts). To obtain proficiency and acquire skill and speed in the different types of surgical manipulations, Susruta devised various experimental modules for trying each procedure. Incision and excision are to be practiced on vegetables and leather bags filled with mud of different densities; scraping, on hairy skin of animals; puncturing, on the vein of dead animals and lotus stalks; probing, on motheaten wood or bamboo; and scarification, on wooden planks smeared with beeswax. Access to medical training was usually confined to the three higher orders of society,
WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2010.09.007
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but the benevolent Susruta included members of the lowest of the four classes. Sushruta described the need for and way to conduct dissections on human cadavers to gain knowledge of anatomy. He states: “anyone desirous of acquiring a thorough knowledge of anatomy should prepare a dead body and carefully observe, by dissecting it, and examine his different parts; for, a thorough knowledge can be acquired only by comparing the accounts given in the authoritative texts (sastras) with direct observation.” Under his guidance, students used to practice on natural and artificial objects, such as vegetables and leather bags full of water. Quartered sacrificial animals were also used (2-4). Susruta instructed the appropriate day-to-day life of the surgeon in ancient India, who made the rounds of patients’ residences and maintained a consulting room in his own home, complete with a storeroom of drugs and equipment. Although surgeons could command a good living, they might also treat learned Brahmins—priests—and the poor for free. He also described the ideal qualities of a nurse and suggested that surgeons should be required to have a license from the king and take an ethical oath (2-4). In the West, there is a relative lack of recognition, or even awareness, of early Indian contributions to neurosurgery (14) and neuroscience. This is evidenced by the fact that many books on the history of medicine make no mention of ancient Indian medicine. Several factors explain this. First, Sanskrit, which is the language of most ancient texts, is very difficult to master. Second, there are few Sanskrit scholar-physicians available to translate the material into Western languages. Third, the knowledge of ayurveda was guarded as a family secret by people of the priestly class who practiced it. Lastly, one of the reasons is given by Johnston Saint: “Our system of classical education had already given us an apparent beginning for all the arts and sciences. A disproportionate part of our education was devoted to ancient Rome and Greece where we learned all about Apollo and Aesculapius and in Greek history we came to Hippocrates. Here we had got a founder of medicine already for us, and that there might have been anyone before him, few of us were disposed to inquire” (10). The conquest by Arabs of the Indian prov-
SUSRUTA AND ANCIENT INDIAN NEUROSURGERY
ince of Sind (now a part of Pakistan) in the 8th century unleashed a scholarly exchange of scientific ideas. The Susruta Samhita was translated into Arabic and later into Persian. These translations helped to spread the essence of his surgical achievements far beyond India. There also exists another viewpoint, which hints on the direct exchange of scientific ideas and knowledge between Greece and India (by the land route) and between Rome and India (by the sea route with South India).
8. Gordon BL: Medicine Throughout Antiquity. Philadelphia: F.A. Davis; 1949. 9. Hoernle AFR: The Bower manuscript. Facsimile Leaves, Nagari Transcript, Romanised Transliteration and English Translation with Notes (Vol. I). New Delhi: Aditya Prakashan; 1987. 10. Johnston-Saint P: An Outline of the History of Medicine in India. Indian Med Rec 49:289, 1929. 11. Jolly J: Indian Medicine. Delhi: Munshiram Manoharlal Publishers; 1977. 12. Karapurkar AP, Pandya SK: Neurosurgery in India. Neurosurg Rev 6:85-92, 1983.
CONCLUSIONS With the modern-day commercialization of medical science, we need to be reminded of this great ancient surgeon who, despite his unbound successes, maintained the nobility of his profession. Apart from his monumental surgical contributions, including elementary neurosurgery, and his emphasis on practical training in experimental and clinical surgery, it is his compassionate and magnanimous approach that stands out. Susruta says there can be nothing more magnificent than the act of removing human suffering. The science of surgery, including neurosurgery, in addition to being life-giving, should be virtue personified.
13. Keil G: [The history of plastic surgery (author’s transl)]. Laryngol Rhinol Otol (Stuttg) 57:581-91, 1978 [in German]. 14. Liu CY, Apuzzo MLJ: The genesis of neurosurgery and the evolution of the neurosurgical operative environment: Part I. Prehistory to 2003. Neurosurgery 52:3-19, 2003. 15. Major RH: A History of Medicine. Springfield, IL: Charles C. Thomas; 1954. 16. McDowell F: The Source Book of Plastic Surgery. Baltimore: Williams & Wilkins; 1977. 17. Muthu C: The Antiquity of Hindu Medicine and Civilization (3rd ed.). Boston: Milford House; 1931. 18. Neuburger M: History of Medicine. London: H. Frowde [etc.]; 1910. Available at: http://openlibrary. org/b/OL6535528M/History_of_medicine. Accessed February 23, 2010. 19. Raju VK: Susruta of ancient India. Indian J Ophthalmol 51:119-22, 2003.
REFERENCES 1. Bagchi AK: Susruta: a man of history and science. Int Surg 50:403-7, 1968. 2. Bhishagratna K: An English Translation of the Sushruta Samhita Based on Original Sanskrit Text (Vol. I). Kolkata: Kaviraj Kunja Lal Bhishagratna; 1907. 3. Bhishagratna K: An English Translation of the Sushruta Samhita Based on Original Sanskrit Text (Vol. II). Kolkata: Kaviraj Kunja Lal Bhishagratna; 1911. 4. Bhishagratna K: An English Translation of the Sushruta Samhita Based on Original Sanskrit Text (Vol. III). Kolkata: Kaviraj Kunja Lal Bhishagratna; 1916. 5. Bhishagratna KK: The Sushruta Samhita (Vol. I, 2nd ed.). Varanasi: Chowkhamba Sanskrit Series Office; 1963.
20. Ramani PS, Hedge T, Sharma A: A Brief History of Neurosurgery. Mumbai: Lavanya Prints Pvt. Ltd; 1994. 21. Sankaran PS, Deshpande PJ: Susruta. In: Raghvan V, ed. Scientists. Delhi: Publications Division (Govt. of India); 1990:44-72. 22. Sigerist HE: A History of Medicine (Vol. II). New York: Oxford University Press; 1951. 23. Tipton CM: Susruta of India, an unrecognized contributor to the history of exercise physiology. J Appl Physiol 104:1553-6, 2008.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. received 30 June 2010; accepted 10 September 2010 Citation: World Neurosurg. (2011) 75, 2:320-323. DOI: 10.1016/j.wneu.2010.09.007
6. Filliozat J: The Classical Doctrine of Indian Medicine. Varanasi: Munshiram Manoharlal; 1964.
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7. Garrison F: An Introduction to the History of Medicine (2nd ed.). Philadelphia: W.B. Saunders; 1917.
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Susruta and Ancient Indian Neurosurgery Anirban D. Banerjee, Haim Ezer, Anil Nanda
The Golden Age of surgery in ancient India rests largely on the shoulders of Susruta, who lived sometime between 700 and 600 B.C. Susruta practiced and propagated the art of surgery at the University of Benares in that ancient city, located on the banks of the holy Ganges. His monumental treatise on surgery, Susruta Samhita, glorified him as the Father of Indian Surgery. He was the first to systematize “surgery” into two distinct “fields,” including, in essence, what we know today as the field of neurosurgery. The present article elucidates the contributions of this great surgeon from a neurosurgeon’s perspective.
INTRODUCTION Let’s go back in time about 3 millennia. A warrior, with his skull fractured by an axe or a club in the heartland of India, is laid on a large stone block. None of the basic supports we have today exist: no anesthesia as we know it, no antibiotics, no advanced metal instruments, no sterilization of tools, and no proper illumination. The cutting tools are carved out of traditional metals and stone and chipped to produce sharp edges. Perhaps there are some herbal leaves that can be chewed or maybe a potion of wine to effect a little indifference to pain. The wounded scalp is reflected back, and the surgeon begins with the sharpened “tool,” sawing it back and forth, making grooves deep into the skull. If the wound is such that the piece to be removed is polygonal, the grooves overlap at the corners, and when they are deep enough, the piece or pieces are lifted out. Now the surgeon replaces the flap, using ants as staple-sutures. Key words 䡲 Ancient 䡲 Indian 䡲 Neurosurgery 䡲 Susruta From the Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA To whom correspondence should be addressed: Anil Nanda, M.D., F.A.C.S. [E-mail: [email protected]] Citation: World Neurosurg. (2011) 75, 2:320-323. DOI: 10.1016/j.wneu.2010.09.007 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter © 2011 Elsevier Inc. All rights reserved.
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Without antibiotics, the chances for infection are great; the patient may live, or he may die. The “wise” surgeon hopes for the best. The previous description is the typical backdrop that reflects the turbulence surrounding the life and times of the first scientist-surgeon of India: Susruta. Despite all odds, he marched on—unimpressed by his successes and undaunted by his failures. “When the path did not exist, he made one” (16).
disciple of Dhanwantari, and instructs him on the science of surgery. Another version associates Susruta’s tutelage to Divodasa, a physician king of Varanasi (1, 5). This school of thought creates more confusion, however, because some authorities consider Divodasa and Dhanwantari to be the same entity. With ancient India, there is certainty in the existence of the sacred texts associated with Atreya, the world’s oldest record of medical practice (22). Uncertainty prevails, however, concerning whether the “samhita” attributed to Susruta was from a historical figure or from different physicians using a prominent name to give credence to their views (6, 11). The various listed time points related to Susruta include 1000 B.C. (17), 800 – 600 B.C. (19), 600 B.C. (15), 600 –200 B.C. (1), 200 B.C. (8), 1–100 A.D. (18), and 500 A.D. (7). Resolution of these uncertainties has been achieved to a certain extent by the following observations:
y Several Vedic hymns were dedicated to Susruta (10).
REALITY OR MYTH? The very existence of “Susruta” (the name literally means “the one who is well heard”), similar to his times, is shrouded in mythology and controversy. Bass, a German historian, asserted that Susruta had actually been Hippocrates; the name, he justified, had been confounded with Socrates in the Indian tenets and finally transmitted as “Susruta.” Bass based his hypothesis on the fact that Susruta’s birthplace was given as Kasi, an old name for Benares. That was, to him, an obvious distortion of the name of the Greek island of Kos, where Hippocrates was born. Pondering on this apparently distorted version, Gordon (8) commented, “How one clever enough to read Hippocrates in the original and reproduce it in his own language could mistake the name of Socrates for Hippocrates surpasses one’s imagination.” Some say that Dhanwantari, the physician to the gods, descends to earth to minister to the misery and disease of mankind while extolling them in the science of life (10). He subsequently reaches Benares and meets Susruta as the son of Rishi Vishvamitra, a
y Susruta’s description of the human skeleton (“300 bones”) was very similar to the one in the Atreya samhita (10).
y Hoernle’s critical analysis of the ancient Bower Manuscript (9) showed Susruta was a historical figure during 600 B.C. The eminent anatomist and medical historian Keswani noted the various “absurd and amusing theories” that denied the existence of Susruta and wrote (5): “Considering all the evidence available today, one comes to the conclusion that ‘the lowest limit of Sushruta’s death is fixed as the sixth and seventh Century B.C., this being the date of the Satapatha Brahmana, while nothing can be said about the upper limit.” Around 700 – 600 B.C. has been selected for the era of Susruta.
MEDICAL TRAINING Apart from the mythologic impression of Susruta being the son of Saint Vishwamitra, little is known about his ancestors. Susruta is
WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2010.09.007
PEER-REVIEW REPORTS ANIRBAN D. BANERJEE ET AL.
thought to have begun his medical education under Divodasa Dhanvantari, the king of Benares. Divodasa, in his “gurukul,” teaches him the nature of the “purusa” (person) who is afflicted with disease and who is to be treated: the nature of disease that causes pain and its eradication, the types of food, the dravyas, and the time factor. He also asks his students to consult as many other disciplines as necessary to attain sound knowledge in one’s own subject. Among the “alpha-omega-alpha” pupils of Divodasa were Aupadhanava, Aurabhra, Paushkalavata, and Susruta (21); however, Susruta documented and delivered the first focused and stratified treatise on “Salyatantra” (“Salya”—arrow of the enemy; “tantra”—man oeuvre), or surgery.
AS A SURGEON The origin of surgery in India can be traced back to the earliest times, probably back to the Indus Civilization. The Rig-Veda mentions many surgical feats of the celestial twin medical experts, the Asvins. Among the eight divisions of medical knowledge (ayurveda), surgery was considered the first and the most important branch. Surgery held a great deal of importance in ancient India, mainly owing to large-scale warfare, as myriad mutilating injuries inflicted on the apparently never-ending battlefields clamored for effective and expeditious management. Despite an existent knowledge of pharmacopoeia, there was a distinct paucity of a systematic approach to surgical interventions. Surgery in pre-medieval India reached its highest point under Susruta in Benares. He is believed to be the first to bring together the scattered knowledge of surgery and propound a systematic stratification of the science and art of surgery in his “compendium” (“samhita” in Sanskrit): Susruta Samhita. It remains difficult, however, to be absolutely certain whether the Susruta Samhita was composed by Susruta alone or the original author and a number of his subsequent disciples over the next few generations. The entire Susruta Samhita is a complete work on medicine with special attention to surgery, broadly divided into two major fields of surgery: Salya (major surgery) and Salakya (supraclavicular surgeries) tantras. The compendium details about 300 kinds of operations that call for 42 different surgical processes and 121 different types of instruments. The text is long—more than 1700 pages in
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English translation (2-4). The Susruta Samhita is in two parts, the Purva-tantra (the main book) and the Uttara-tantra (an addendum). The Purva-tantra comprises 120 chapters arranged in five sections, as follows:
y Sutra Sthana: fundamental principles y Nidana Sthana: etiology and clinical features
y Sarira Sthana: anatomy and physiology y Cikitsa Sthana: therapeutics y Kalpa Sthana: toxicology The entire Uttara-tantra has been called Aupadravika because many of the complications of surgical procedures are briefly described here. Susruta emphasizes that removal of foreign bodies is fraught with certain complications if the seat of the Salya be a “marma” (eloquent area). These two parts together encompass, apart from Salya and Salakya, the other specialties of medicine, including pediatrics, geriatrics, toxicology, aphrodisiacs, and psychiatry. Susruta emphasizes in his text that unless one possesses adequate knowledge of relevant allied branches, one cannot attain proficiency in one’s own subject of study. The succinct style and the overall superiority of the Susruta Samhita led to the minimization of other preceding or contemporary treatises.
CONTRIBUTIONS TO NEUROSURGERY AND NEUROSCIENCE Neurosurgery Neurosurgery in ancient India takes its roots from the mythologic description of transplantation of the head (exemplified by the implantation of head of an elephant on Lord Ganesha) in ayurveda. Trephination and the removal of an intracranial mass by Jivaka (surgeon to Lord Buddha) have been documented also (12, 19). The master surgeon Susruta is said have included elementary neurosurgery in his accomplishments: “Ten nerves maintain the functions of the body by carrying impulses of sound, touch, vision, taste, smell, respiration, sighing, yawning, hunger, laughing, speech, and crying . . .” “A pair of nerve each responds to sound, touch, vision, taste, and smell.”
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“Two nerves lower down at the back of ear (vidhura) which if cut produce deafness; a pair of nerves inside the two nostrils which if cut cause anosmia; a pair of nerves below the end of the eyebrow which if cut causes blindness.”—Susruta Samhita. Susruta considered the head as the center of all functions. Through his immaculate dissections, he vividly described the cranial nerves including the optic and vestibulocochlear nerves in cadavers and hypothesized their physiologic importance. Susruta also attaches importance to neuroembryology in the Sarira-sthana (21) section: “In the fifth month the fetus is endowed with the mind and wakes up from the sleep of his subconscious existence. In the sixth month cognition (Buddhi) comes in. In the seventh month all the limbs and members of its body are markedly developed. Sanuka says that probably the head of the fetus is the first developed since head is the only organ that makes the functions of all other organs possible.” In the Uttara-tantra section (3), Susruta discusses his experiences with supraclavicular surgeries or salakya-tantra. Apart from extensive discussions of diseases of eyes, ear, and nose, he dwells on surgical procedures involving the head and pertaining to the cranial structures, mainly dealing with warfare injuries, including trephining, excising, probing, puncturing, suturing, and evacuating “collected” fluids. The 22nd chapter of the Uttaratantra also describes a condition that could well be post-traumatic cerebrospinal rhinorrhea: “Kshavathu is said to be of two kinds (1) Doshaja and (2) traumatic.” Susruta’s method of treating spinal injuries reflects his great knowledge on the subject (20). On the treatment of cervical spine dislocation, he instructed to grasp the head at the neck along with the angle of the jaw and lift it up.
Susruta’s Instruments Susruta describes a variety of blunt and sharp instruments for distinct surgical procedures, including cranial and spinal surgeries, and adds that a surgeon, by his own experience and intelligence, may invent new instruments to facilitate the surgical procedures. He claims, however, that “the hand” is the most important and the best instrument. The blunt instruments are meant for removal of foreign
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bodies, for sucking the fluids, for facilitating the various surgical procedures, and for visualizing. The double-armed axial instruments are called swastika-yantras, resembling the modern forceps. Susruta’s classification and description became the basis for the development of instruments. He was apparently the first person to introduce the diagnostic instruments and their principles, which were modified later with the introduction of optic support (2-4).
Neurology Susruta terms the various disorders (and related remedies) of nervous system as Shiroroga, relating them to Vatavyadhi (disorders of Vayu) (3). He elaborates on akshepaka (convulsions), pakshavadha (hemiplegia), ardita (total paralysis), danda patanka (Parkinson disease), manya sthamba (stiff neck), jihavasthamba (paralysis of tongue), gridarasi (sciatica), murcha (fainting), dhanushsthamba (tetanus), and apasmara (epilepsy) in the related chapters of his treatise.
Psychiatry Susruta places great importance on the necessity of a healthy mind for a prosperous life. In the Sutra-sthana section of Purva-tantra, Susruta describes in great detail the diseases pertaining to manasa (mental health). Excessive anger, grief, fears, joy, despondency, envy, misery, pride, greed, lust, desire, and malice are included within the category of manasa disorders. A plant called “soma,” which is described in the early texts but has never been clearly identified, was recommended as a treatment for rejuvenating body and mind. Susruta explains the need of all living creatures to sleep and to dream as a function of two principles of the mind that give glimpses of previous existences or warn of future ill health. When both principles are weakened, coma results (2-4).
CONTRIBUTIONS TO THE SCIENCE OF SURGERY Susruta describes various types of surgical procedures: chedana (excision), bhedana (incision), lekhana (scraping), scooping, vyadhana (puncturing with special instrument), esana (probing), sravana (blood-letting), and svana (suturing) (2-4). Some salient presurgical procedures, such as cauterization by Ksaras
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(alkaline substances) or Agni and application of leeches, were being practiced by Susruta. Thermal cauterization for therapeutic purposes has been advocated by heating various substances and applying them at the desired sites. Susruta points out that hemorrhage can be arrested by apposition of the cut edges with stitches, application of styptic decoctions, or cauterization with chemicals or heat (2-4). He advocates the use of wine as an anesthetic. Although the use of henbane (Cannabis indica) and of Sammohini and Sanjivani are reported at a later period, Susruta might be considered as a pioneer in this regard. The progress of surgery and its development is closely associated with the great wars of the past. A major contribution of Susruta is in the subject of trauma and critical care. He speaks of six varieties of accidental injuries encompassing almost all parts of the body. Susruta also classifies the bones and their reaction to injuries, varieties of dislocation of joints (sandhimukta), and fractures of the shaft (kanda-bhagna). He classifies the 6 types of dislocations and 12 varieties of fractures. He propounds the principles of fracture treatment, as follows: traction, manipulation, appositions, and stabilization, including measures of rehabilitation. Susruta illustrates the vrana or injury as involving the breakdown of body components, such as skin, flesh, blood vessels, sinews, bones, joints, and internal organs. Classically, vrana, the wound, is the ultimate explosion of the underlying pathologic structure. “The sixth stage of a continuous process, which starts with sotha (inflammation). In the first stage, the ulcer is unclean and hence called a dusta-vrana; following treatment it becomes a suddha-vrana; there is a subsequent attempt at healing and is called ruhyamana-vrana and when the ulcer is completely healed, it is a rudha-vrana.”—Susruta Samhita. Fourteen types of bandaging capable of covering almost all the regions of the body are described for the practice of the student on dummies. Susruta has elucidated the four degrees of accidental burns, the effects of heatstroke and sunstroke, the effect of frostbite from excessive cold, and the effect of lightning, which he calls vidyut-dagdha (2-4). Susruta presents the basic principles of plastic surgery: accuracy, precision, economy, hemostasis, and perfection. He advocates proper physiotherapy before the operation and describes various methods or different types of defects, such as (i) release of the skin for covering small defects, (ii) rota-
tion of the flaps to make up for the partial loss, and (iii) pedicle flaps for covering complete loss of skin from an area. He mentions various methods including sliding graft, rotation graft, and pedicle graft. Nasal repair or rhinoplasty has been described in greater detail, which to this day has stood the test of time and is mentioned as the Indian method of rhinoplasty in textbooks of plastic surgery. The procedure was observed in India by a British surgeon in 1793 and published in London the following year, changing the course of plastic surgery in Europe (13). Susruta was very familiar with the signs and symptoms, methods of extraction, and operative complications of various types of urinary stones. In addition, he describes surgery of intestinal obstruction (baddhagudodara), perforated intestines (chidrodara), and accidental injuries to the abdomen (assaya-bhinna). The Susruta Samhita describes methods of management of hemorrhoids and fistulas, describing different types of incision to remove different fistulous tracts (langalaka, ardhalangalaka, sarvabhadra, candraadha [curved] and kharjurapatraka [serrated]), analogous to a modern general surgery practice. Susruta also describes various types of cataracts and the procedure of couching. It is also stated that he contributed to the introduction and practice of the technique of cesarean section (5, 6, 22). In the area of exercise physiology, Susruta stressed the importance of regular and disciplined exercise in maintaining equilibrium among the three “humors” of life to prevent and expedite the cure of various diseases (23). Sausruts Another probable “first” that can be credited to Susruta is his establishment of a structured training program, spanning 6 years, for his disciples (sausruts). To obtain proficiency and acquire skill and speed in the different types of surgical manipulations, Susruta devised various experimental modules for trying each procedure. Incision and excision are to be practiced on vegetables and leather bags filled with mud of different densities; scraping, on hairy skin of animals; puncturing, on the vein of dead animals and lotus stalks; probing, on motheaten wood or bamboo; and scarification, on wooden planks smeared with beeswax. Access to medical training was usually confined to the three higher orders of society,
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but the benevolent Susruta included members of the lowest of the four classes. Sushruta described the need for and way to conduct dissections on human cadavers to gain knowledge of anatomy. He states: “anyone desirous of acquiring a thorough knowledge of anatomy should prepare a dead body and carefully observe, by dissecting it, and examine his different parts; for, a thorough knowledge can be acquired only by comparing the accounts given in the authoritative texts (sastras) with direct observation.” Under his guidance, students used to practice on natural and artificial objects, such as vegetables and leather bags full of water. Quartered sacrificial animals were also used (2-4). Susruta instructed the appropriate day-to-day life of the surgeon in ancient India, who made the rounds of patients’ residences and maintained a consulting room in his own home, complete with a storeroom of drugs and equipment. Although surgeons could command a good living, they might also treat learned Brahmins—priests—and the poor for free. He also described the ideal qualities of a nurse and suggested that surgeons should be required to have a license from the king and take an ethical oath (2-4). In the West, there is a relative lack of recognition, or even awareness, of early Indian contributions to neurosurgery (14) and neuroscience. This is evidenced by the fact that many books on the history of medicine make no mention of ancient Indian medicine. Several factors explain this. First, Sanskrit, which is the language of most ancient texts, is very difficult to master. Second, there are few Sanskrit scholar-physicians available to translate the material into Western languages. Third, the knowledge of ayurveda was guarded as a family secret by people of the priestly class who practiced it. Lastly, one of the reasons is given by Johnston Saint: “Our system of classical education had already given us an apparent beginning for all the arts and sciences. A disproportionate part of our education was devoted to ancient Rome and Greece where we learned all about Apollo and Aesculapius and in Greek history we came to Hippocrates. Here we had got a founder of medicine already for us, and that there might have been anyone before him, few of us were disposed to inquire” (10). The conquest by Arabs of the Indian prov-
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ince of Sind (now a part of Pakistan) in the 8th century unleashed a scholarly exchange of scientific ideas. The Susruta Samhita was translated into Arabic and later into Persian. These translations helped to spread the essence of his surgical achievements far beyond India. There also exists another viewpoint, which hints on the direct exchange of scientific ideas and knowledge between Greece and India (by the land route) and between Rome and India (by the sea route with South India).
8. Gordon BL: Medicine Throughout Antiquity. Philadelphia: F.A. Davis; 1949. 9. Hoernle AFR: The Bower manuscript. Facsimile Leaves, Nagari Transcript, Romanised Transliteration and English Translation with Notes (Vol. I). New Delhi: Aditya Prakashan; 1987. 10. Johnston-Saint P: An Outline of the History of Medicine in India. Indian Med Rec 49:289, 1929. 11. Jolly J: Indian Medicine. Delhi: Munshiram Manoharlal Publishers; 1977. 12. Karapurkar AP, Pandya SK: Neurosurgery in India. Neurosurg Rev 6:85-92, 1983.
CONCLUSIONS With the modern-day commercialization of medical science, we need to be reminded of this great ancient surgeon who, despite his unbound successes, maintained the nobility of his profession. Apart from his monumental surgical contributions, including elementary neurosurgery, and his emphasis on practical training in experimental and clinical surgery, it is his compassionate and magnanimous approach that stands out. Susruta says there can be nothing more magnificent than the act of removing human suffering. The science of surgery, including neurosurgery, in addition to being life-giving, should be virtue personified.
13. Keil G: [The history of plastic surgery (author’s transl)]. Laryngol Rhinol Otol (Stuttg) 57:581-91, 1978 [in German]. 14. Liu CY, Apuzzo MLJ: The genesis of neurosurgery and the evolution of the neurosurgical operative environment: Part I. Prehistory to 2003. Neurosurgery 52:3-19, 2003. 15. Major RH: A History of Medicine. Springfield, IL: Charles C. Thomas; 1954. 16. McDowell F: The Source Book of Plastic Surgery. Baltimore: Williams & Wilkins; 1977. 17. Muthu C: The Antiquity of Hindu Medicine and Civilization (3rd ed.). Boston: Milford House; 1931. 18. Neuburger M: History of Medicine. London: H. Frowde [etc.]; 1910. Available at: http://openlibrary. org/b/OL6535528M/History_of_medicine. Accessed February 23, 2010. 19. Raju VK: Susruta of ancient India. Indian J Ophthalmol 51:119-22, 2003.
REFERENCES 1. Bagchi AK: Susruta: a man of history and science. Int Surg 50:403-7, 1968. 2. Bhishagratna K: An English Translation of the Sushruta Samhita Based on Original Sanskrit Text (Vol. I). Kolkata: Kaviraj Kunja Lal Bhishagratna; 1907. 3. Bhishagratna K: An English Translation of the Sushruta Samhita Based on Original Sanskrit Text (Vol. II). Kolkata: Kaviraj Kunja Lal Bhishagratna; 1911. 4. Bhishagratna K: An English Translation of the Sushruta Samhita Based on Original Sanskrit Text (Vol. III). Kolkata: Kaviraj Kunja Lal Bhishagratna; 1916. 5. Bhishagratna KK: The Sushruta Samhita (Vol. I, 2nd ed.). Varanasi: Chowkhamba Sanskrit Series Office; 1963.
20. Ramani PS, Hedge T, Sharma A: A Brief History of Neurosurgery. Mumbai: Lavanya Prints Pvt. Ltd; 1994. 21. Sankaran PS, Deshpande PJ: Susruta. In: Raghvan V, ed. Scientists. Delhi: Publications Division (Govt. of India); 1990:44-72. 22. Sigerist HE: A History of Medicine (Vol. II). New York: Oxford University Press; 1951. 23. Tipton CM: Susruta of India, an unrecognized contributor to the history of exercise physiology. J Appl Physiol 104:1553-6, 2008.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. received 30 June 2010; accepted 10 September 2010 Citation: World Neurosurg. (2011) 75, 2:320-323. DOI: 10.1016/j.wneu.2010.09.007
6. Filliozat J: The Classical Doctrine of Indian Medicine. Varanasi: Munshiram Manoharlal; 1964.
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7. Garrison F: An Introduction to the History of Medicine (2nd ed.). Philadelphia: W.B. Saunders; 1917.
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