FEATURE

Ophthalmology in ancient , ’s time and the modern era

BY DHIREN BUJARBORUA

hile reading an article Sushruta’s time has long been a encountered while doing the . related to the history of controversial subject due to a lack of Several reasons, such as translation Indian , direct evidence [3]. The original copy of the original work by a non- W I came across this of Sushruta , the monumental medical scholar, difficulty in description of a surgical procedure: treatise on surgery written by interpreting Vedic Sanskrit and the “The doctor warmed the patient’s Sushruta, is not traceable. However, understanding of at that time eye with the breath of his mouth. He a version of this textbook was might lead to this confusion. Recently rubbed the closed eye of the patient discovered in 1890 in Kuchar, Chinese there has been some debate whether with his thumb and then asked the Turkestan, and was named after the we should consider the operation patient to look at his knees. The man to whom it was sold, Hamilton done by Sushruta to be extracapsular patient’s head was held firmly. The Bower. The is cataract extraction or couching [7,8]. doctor held the lancet between his currently housed in the Bodlean But in ancient times, cataractous fore-finger, middle-finger and thumb Library in Oxford [4]. Hoernle edited lenses were dislocated into the and introduced it into the patient’s and critically evaluated it and placed vitreous cavity rather than removed eye towards the pupil, in the strict sense. half a finger’s breadth Sushruta unknowingly from the black of the might have done some eye and a quarter of a partial extracapsular finger’s breadth from lens extraction in the outer corner of cases with mature or the eye. He moved the hypermature cataract lancet gracefully back while attempting and forth and upward. displacement of There was a small opaque lens from sound and a drop of the pupillary area water came out. The (couching). doctor spoke a few Nevertheless, it words to comfort the is really amazing to patient and moistened note that in the later the eye with milk. He part of the ‘Vedic Age’ scratched the pupil (3000 to 1000 BC), a ©Alokprasad at en.wikipedia with the tip of the dared to enter lancet, without hurting, the eye with a lancet and then drove the ‘slime’ towards the its origin around fifth century BC. As to remove the lens opacity. Couching nose. The patient got rid of the ‘slime’ Sushruta’s name was found in this became a very popular procedure for by drawing it into his nose. It was a document, it is presumed that he removal of blindness due to cataract. matter of joy for the patient that he must have existed in the fifth century The analogy of Buddha removing the could see objects through his operated BC or earlier [3]. Sushruta is the most screen of ignorance using a probe of eye and the doctor drew the lancet out celebrated physician and surgeon in wisdom to the surgeon who removes slowly. He then laid cotton soaked in India. Many of his contributions to cataract with a metallic probe is often fat on the wound and the patient lay and surgery preceded similar found in Buddhist literature. Even still with the operated eye bandaged. discoveries in the western world [5]. a symbolic cataract operation was It was the patient’s left eye and the Sushruta practiced medicine nearly imitated at the time of initiation of doctor used his right hand for the 150 years before [6]. monks at that time [9]. operation.” The steps of the operation definitely It was quite natural that people at This is the description of an indicate that it was done for removal that period of time tried some non- operation that was performed by of the opacity of cataractous lens surgical measures to cure cataract Sushruta, India’s greatest surgeon of though there was some confusing before the development of the surgical the pre-medieval period [1,2]. interpretation of the findings remedy. In one such approach, a fully

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developed dead cobra was put into a jar of milk along with four scorpions, and was kept aside to degenerate and decay in the milk for about a period of 21 days. After that the milk was churned into butter. This butter was fed to a cockerel. The faecal matter of this cockerel was applied to the eye with the hope of curing the eye of cataract [2].

Ancient knowledge The , the oldest sacred books of the Hindu religion are considered to be the first record of the ancient knowledge and civilisation of India, but also of the whole world. There are four Vedas, which were compiled in Sanskrit language between 3000 to1000 BC. Most of the early Vedic medicine was compiled in one of the four Vedas, known as . Superstition Figure 1: The or Sahottara- (A Treatise on Ayurvedic Medicine). Source: Los Angeles and magic is seen in Atharvaveda and County Museum of Art. the cures suggested are both magic spells and plant remedies [10]. The running to 1700 pages in its English surgical procedures in his Samhita [11]. ancient Indian system of medicine translation [13]. As a textbook, it is He was the first surgeon to systemise and surgery is commonly known unrivalled in respect of composite surgery by dividing it into separate as (science of life). This teaching on the subject, as it included fields. He is known as the originator was given the status of ‘Upa Veda’ information about all allied branches of , cataract operation, (supplementary subject of Veda) or of medical learning required by a and vesical [3]. fifth Veda in the next stage of growth. surgeon [11]. The original Sushruta He was aware of angina and the ill Among the available literatures three Samhita was revised by in effects of obesity. He also knew about ‘’ (compendiums) – Sushruta, the second century AD. Nagarjuna was diabetes and was aware of the benefits and Astanga Hridaya are a great Buddhist teacher. The Samhita of physical exercise in controlling this currently the chief source of knowledge was again re-edited by Chakrapani disease. Tipton [17] rightly observed of Ayurveda [11]. In fact, the first in the 11th century [6]. The Samhita that Sushruta’s concepts pertaining rational approach to medical science contains 184 chapters and description to the health benefits of exercise were is seen in the composition of Sushruta of 1120 illnesses, 700 , “remarkably modern.” He is credited and in the pre- a detailed study of anatomy, 64 with performing cosmetic surgery and Buddhist period [10]. preparations from mineral sources and especially using forehead The oldest treatise dealing with 57 preparations from animal sources. skin to reconstruct noses which were surgery is the Sushruta Samhita. Sushruta devoted 18 chapters to usually amputated as a punishment for Sushruta was possibly born in the describing 76 eye diseases, of which 51 crimes in his era [1,6]. This rhinoplasty seventh century BC. He practiced required surgical treatment. Sushruta operation eventually changed the and taught the art of surgery at the Samhita was written in the aphorism course of plastic surgery in Europe. University of Benares in the ancient form and the techniques described in it Indian ophthalmic tradition started city of the same name, located on the are eminently in line with the technical much earlier than Sushruta’s time. bank of the river Ganges that flows abilities of the times [11,14]. Indeed, India had a long tradition through the northern part of India Sushruta was one of the first in the of ophthalmic study and practice [3,12]. The followers of Sushruta were world to study the human anatomy starting from the legendary King Nimi called Saushrutas. The new student with the aid of a preserved dead body. of Videha (located in what is now was expected to study for at least six He was the first person who established the eastern Terai-Madhesh region years. Before starting his training he the technique of preservation of dead of and the northern Indian had to take a solemn oath, which can bodies [1,15]. Sushruta had devised state of Bihar). This great king was be compared to that of Hippocrates various experimental models for trying considered to be the founder of the [12]. Sushruta had superb observational surgical procedures for the students science of ophthalmology in India. It power and a sharp analytical mind. before trying their hands on actual was Nimi who first gave instructions for Sushruta Samhita established him patients [16]. operation on a cataract. The knowledge as the ‘Father of Indian Surgery’ or Sushruta described surgery under of ophthalmology, as well as other rather ‘Father of surgery in the world’ eight heads – excision (Chedya), aspects of medical science, was passed [3,11,13,14]. The Sushruta Samhita was scarification (Lekhya), puncturing through king Nimi to Sushruta and a textbook of surgery in those days (Vedhya), exploration (Esya), extraction Nagarjuna of second to fourth century and was studied by the students of (Ahrya), evacuation (Vsraya) and AD, Vagbhaa of sixth century AD and so medicine more than 2000 years ago. suturing (Sivya) [1]. He described over on up to pre-modern times [9]. The text of the Samhita was quite long, 120 surgical instruments and 300 The procedure of the cataract

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surgery described in Sushruta Samhita System also became popular in Europe the healthcare of their own people into might have been transmitted to the and helped to form the foundation of the hands of Ayurvedic physicians and west by Greek travellers from India and the European tradition of medicine [6]. Unanis. They had to bring medical men the Middle East [18]. This procedure Though ancient India made from their own country. The British was also introduced into from mindboggling advances in medical trained a few Indians in the India via the silk route during the science, this was unknown in the West elementary principles of diagnosis and late West Han Dynasty (206 BC – 9 until recent times. The main reason the treatment of disease and appointed AD). In China, it was combined with is that old Indian texts were written them as ‘native doctors’. Seeing the Chinese concept of acupuncture in Sanskrit and only a few Sanskrit the dedication of these people, the [19]. The first reference to cataract scholar-physicians are available to Medical Board of the British Surgeons and couching as its treatment in the translate the material into western thought of providing a more systematic west is found in 29 BC. It was adapted languages. Also, interestingly, the education. With a Government Order all over the world till the French knowledge of Ayurveda was guarded as dated 21 June 1822, the first medical ophthalmologist Jaques Daviel did the a family secret by people of the priestly school in British India was established. first successful extracapsular cataract class who practised it in ancient times The school opened in October 1824 extraction in April 1747 [18]. Though [3]. at Calcutta Sanskrit College. The the technique of The period between 500 AD and period of training was for three years. changed rapidly, the ancient procedure 1500 AD is called the ‘dark age of In 1833 Lord William Bentinck, the was carried out by wandering vaidyas, medicine’ all over the world [6]. The then Governor of India, took initiative hakims or barbers up to the 20th caste system which had crept into in establishing a medical college for century [9], however, this procedure is the Indian society and the taboo of Indians [6]. not always effective and at times may dissecting dead bodies hampered However, long before the turn out to be dangerous. the expansion of the knowledge of establishment of Calcutta Medical Ancient Indians understood the medical science in India. However, College in 1835, the East India anatomy of the eye only as much as can during this period, Arabs advanced a Company had a small eye infirmary be perceived from the exterior. They lot in comparison to other civilisations. in Halliday Street, Calcutta. In 1880, did not have any idea about the retina Graeco-Roman was this eye infirmary was shifted to or optic nerve. This indicates that their translated into Arabic. They founded Medical College Hospital. A separate knowledge about the eye was not based medical schools and hospitals in eye infirmary was opened in 1928. on practical dissection of the organ. Baghdad, Damascus, Cairo and other During the Second World War, the They had some idea about the lenses Muslim capitals. The ‘golden age’ of eye infirmary gained prominence inside the eye for quite some time, but Arabic medicine was between 800 and by receiving and treating the eye the correct idea about its location came 1300 AD [6]. casualties from the Burma front [6]. only by the 12th century AD [9]. The domination of Indian medicine By the 19th century, there was Ancient Indian philosophers gradually declined with the spread of considerable improvement in contributed substantially to the Islam during the middle ages. With various fields of medicine, including development of ideas of visual the arrival of Muslims in India, Hindu ophthalmology, and the healthcare mechanism. The contribution of an medicine lost its importance due to the system in India. After the ‘British outer source of light and cognitive lack of state help and support by the Raj’, a significant milestone in the power was known all along but rulers. The Muslim rulers introduced development of ophthalmology in India there was confusion as to the seat of the Unani system of medicine and by was the growth of the department of perception. The brain as a physical the 13th century, the Unani system was ophthalmology at the All India Institute entity was not recognised, again due to firmly established in places like Delhi, of Medical Sciences, New-Delhi to the the taboo of dissecting a cadaver [9]. Aligarh, Lucknow and Hyderabad. This Dr RP Centre for Ophthalmic Sciences Sushruta Samhita described continued until the eighteenth century in 1967. The institute grew between for conditions like cataract, pterygium, when, with the arrival of the British in 1967 to 1986 to a 300 bed eye hospital trichiasis and entropion. Diseases like the 18th century, the Ayurvedic system with 12 operation theatres, 25 full- glaucoma were treated by relieving was revived again along with the time faculty, with basic sciences and ocular pressure by inserting a needle or Western system of medicine [6]. community ophthalmology wings and using leeches [9]. providing training to 72 junior residents The modern era and 25 senior residents – one of the The ‘golden’ and ‘dark’ ages By the late 19th and 20th centuries, largest residency training programmes The ‘golden age’ of Indian medicine was almost every civilised area on the in the world [20]. During this period between 800 BC and 600 AD. Learned globe saw a new trend in art, politics, some sophisticated eye institutes were men from China, Tibet, Afghanistan, science and culture. The modern era also built in the southern part of India. Greece, Rome, Egypt and Persia came of science is closely associated with Now, every state of India has several to the Indian Ayurvedic Schools to technological progress, which has lead medical colleges with well-equipped learn about this system of medicine. to many discoveries and changes in eye departments, and many of the Ayurvedic texts were translated into our understanding of many diseases. states have ophthalmic institutes of Arabic by physicians like The advent of the modern science of international standard in both the (Ibu Sina) and Razi Sempion. Both of ophthalmology is essentially a Western government and private sectors. It them quoted Indian Ayurvedic texts phenomenon [9]. seems there is a bright future for and established the Islamic medicine In the early 19th century, the British Indian ophthalmology. The younger ‘Unani System’. This Indian Ayurvedic Government of India could not entrust generation should be able to regain the

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lost glory of Indian ophthalmology, as 6. Roy H. with Special Reference to 19. Chan C-C. Couching for in China. Survey of India. Histopathology India. www.histopathology- ophthalmology. Surv Ophthalmol 2010;55(4):393-8. there is no dearth of talent or patients. india.net/history_of_medicine.htm Last accessed 20. Prof Madan Mohan sees changes, promising future Lastly, while researching this article, April 2015. for Indian Ophthalmology. Ocular Surgery News, Asia I was amazed to notice that many of 7. Mehta H. Extra-capsular cataract removal – not Pacific Edition. couching – pioneered by Sushruta. Surv Ophthalmol the ancient kings and spiritual leaders 2011;56:276-7. of India were the great physicians / 8. Grzybowski A, Ascaso FJ. Sushruta did not introduce surgeons of that period of time. Even extracapsular cataract removal. Surv Ophthalmol 2012;57(6):584. the teacher of Sushruta was a king. But 9. Despande VJ. Ophthalmic ideas in ancient India. why did the kings themselves became Indian Journal of 2013;48(2):175- physicians? Was it because the common 205. 10. Despande V. Ancient Indian medicine and its spread people looked towards them for every to China. Economic and Political Weekly 2001;36(13). problem in life? Or did they consider the 11. Sing RK, Vyas MK. Surgical procedures in Sushruta act of treating the sick and giving life to Samhita. IJRAP 2011;2(5):1444-50. the dying to be of great virtue? 12. Saraf S, Parihar R. Sushruta: The first plastic surgeon in 600 BC. The Internet Journal of Plastic Surgery 2006;4(2). https://ispub.com/IJPS/4/2/8232 Last accessed April 2015. References 13. Kansupada KB, Sassani JW. Sushruta: The father of 1. Ancient India’s Contribution to MEDICAL SCIENCE. Indian surgery and ophthalmology. Doc Ophthalmol Hindu Books. http://www.hindubooks.org/ 1997;93:159-67. Dr Dhiren Bujarborua, sudheer_birodkar/india_contribution/medicine. 14. Dwivedi G, Dwivedi S. Sushruta – the clinician – Managing Director, html Last accessed April 2015. teacher par excellence. Indian J Chest Dis Allied Sci Pragjyoti Eye Care 2. Ramachandran CK. Nimi Tantra (Ophthalmology of 2007;49:243-4. & Research Centre, Ancient India). Ancient Science of Life 1984;3(4): 15. Loukas M, Lanteri A, Ferrauiola J, et al. Anatomy in 29 Mother Teresa Road, 183-7. ancient India: a focus on the Susruta Samhita. J Anat 3. Raju VK. Susruta of ancient India. Indian J 2010;217(6):646-50. Guwahat, 781021, Assam, India. Ophthalmol 2003;51:119-22. 16. Yogitha B. Mock surgeries in Ayurveda. IRJP 4. Grzybowski A, Ascaso FJ. Sushruta in 600 B. C. 2012;3(10). introduced extracapsular extraction of lens material. 17. Tipton CM. Susruta of India, an unrecognized Acta Ophthalmol 2014:92:194-7. contributor to the history of exercise . Declaration of Competing Interests 5. Sharma HS, Sharma HI, Sharma HA. Sushruta- J Appl Physiol 2008;104(6):1553-6. None declared. samhitA - A critical Review Part-1 : Historical 18. Ascaso FZ, Huerva V. History of cataract surgery. glimpse. Ayu 2012;33(2):167-73. Med Secoli 2009;21(1):75-89.

eye news | AUGUST/SEPTEMBER 2015 | VOL 22 NO 2 | www.eyenews.uk.com