Susruta is known as the Father of Surgery, but he also pioneered the treatment of eye diseases, writes Dr V.K. Raju, an eminent ophthalmologist.
Susruta was undoubtedly a man ahead of his time, but it can be said, too, that he was perhaps the most forward thinking—and, perhaps, the most prolific—when it came to ophthalmology. In his text, he categorizes and explains various parts of the body, but devotes a full 18 chapters in his treatise, titled Susruta Samhita, to diseases of the eye and within those chapters is a detailed description of cataract surgery, which he pioneered.
According to the surgeon, the eye, which “resembles the teat of a cow,” embodies the five basic elements: the solid earth (Bhu) forms muscles, heat (Agni) is in the blood that courses through the veins and arteries, air (Vayu) forms the black part of the eyes (the iris and pupil), the fluid element (Jala) forms the lucid part (vitreous), and the void (Akasa) forms the lacrimal ducts and sacs for discharge of secretions. He also outlines five anatomical subdivisions of the eye: eyelashes (Pakshma–mandala); the eyelid (Vartma-mandala); the sclera/cornea (Sveta- or Sukla-mandala); the choroid (Krishna-mandala); and the pupil (Drishti-mandala), which “looks like a hole and is the size of a Lentil seed.”
In this essay, we will discuss just a few of the eye diseases and surgeries outlined in the Susruta Samhita, with a special focus on their modern relevance. First, we’ll examine Susruta’s treatment of pterygium (arman), which is a growth that covers the sclera—the white of the eye—and “extends onto the cornea.” Modern physicians have affirmed that pterygium can be caused by prolonged exposure to sunlight, so Susruta, who lived close to the equator, must have been rather familiar with it.
Susruta’s techniques (paraphrased here for brevity) for treating pterygium are similar to the techniques used today:
“Perioperatively the eye is irrigated with saindhava salt and soaked with a warm compress. The patient faces the surgeon while sitting and is asked to look at the outer corner of his affected eye. The lids are held wide apart and the pterygium is secured with a hook and held with a threaded needle. This is then excited at its base with the mandalagra instrument. The root of the Pterygium should be pushed asunder from the cornea and then removed.”
Susruta’s treatise, written some time in the 6th-8th century BC, describes 76 eye conditions including 51 needing surgery, as well as many ophthalmological surgical instruments and techniques. His description of cataract surgery was compatible with what is now called couching.
Although modern pterygium surgery is slightly different than what Susruta describes, there are some similarities: the lids are still held wide apart (with a lid speculum), and the surgery still focuses on the excision of the pterygium.
Susruta also discusses the treatment of trichiasis (pakshma-kopa) in his treatise. Trichiasis is a condition marked by unusually positioned eyelashes that rub painfully on the eyeball. Trichiasis can eventually lead to vision loss unless it is treated. Susruta describes its treatment in a way that is not dissimilar from a modern technique (instructions paraphrased here for clarity):
“After being treated with sneha (a special diet) the patient sits facing the surgeon. An excision in the shape and size of barleycorn should be made in the eyelid horizontally parallel having two parts below the eyebrow and one part above the eyelashes. The surgeon should then suture up the two edges with horse’s hair. After suturing, honey and ghee should be applied. A piece of linen should be tied around the forehead and the horse’s hair [i.e., the sections of the eyelid now sutured together] should be attached thereto. The sutures are removed once there is adhesion of the two edges. If this does not succeed, cauterization of the upper lid or complete epilation should be performed.”
Although the use of honey, ghee, and horse hair does not seem modern, Susruta’s basic technique is still employed today. It is still recommended that the surgeon split the eyelid horizontally above the eyelashes and rotate it away from the eyeball, and the eyelid is still sutured, but with more modem materials—namely absorbable sutures or silk.
One of Susruta’s most notable achievements is his work related to cataract surgery. A “cataract is a clouding of the eye’s lens that can occur in either or both eyes and results in blurry vision.” It’s most often caused by aging, but like
pterygium, it can be caused by continued exposure to sunlight. Although it is little used today, the technique he describes (which modern ophthalmologists call “couching”) was once practiced for centuries all over the world. It was a major development in Susruta’s time and was relatively effective, in that it at least allowed patients to experience some sense of vision, rather than absolute blindness. A summary of the procedure follows:
“In neither too hot nor too cold a weather, the patient should be subjected to oleation and sedation therapies. He should then be made to sit and positioned properly after which he should be asked to fix his gaze towards his own nose continuously. Then the intelligent surgeon should hold a barley-shaped salaka instrument between the thumb, middle finger and index finger of his right hand and should open the eyes and puncture the eyeball properly with confidence towards the temporal canthus avoiding two parts of the white of the eye from the cornea. The puncture should be made neither too high nor too low, nor at the sides and saving the network of veins. It should then be directed towards the natural orifice. The surgeon should operate with his right hand on the left eye and with his left hand on the right eye. The proper puncturing is recognized by the production of a (typical) sound and by the outflow of a drop of liquid.
“As soon as the puncture has been done, the salaka should be held firmly in the proper position while the eye should be irrigated with human milk and fomented with vata-pacifying leaves from outside, irrespective of the dosa being stable or mobile. Then (the substance of) the lens should be punctured and scraped with the point of the salaka and the patient should be made to blow out violently the kapha accumulated in the lens after closing the nostril of the opposite side.”
We must pay attention to history to appreciate the discoveries and breakthroughs that laid the groundwork for medicine as we know it now. Susruta’s writings on the eye and its diseases will always be relevant, for they are part of the history of modern ophthalmology—and a part of India’s rich and varied history.
It is immediately clear that Susruta had a lot to say about cataract disease — after all, he is said to have been the first person to do cataract surgery, so it’s understandable that his explanation would be thorough. But what can a layperson glean from Susruta’s descriptions of the treatment of eye diseases, and of cataracts, specifically? Actually, quite a bit.
In his Susruta Samhita, the ancient surgeon gives the modern reader a glimpse into the process of cataract surgery in its earliest stage of practice and development. It is hard to imagine scheduling a surgery around the weather, for instance, and some might be tempted to judge the entire description as outdated because of that one line. However, Susruta’s technique was quite advanced; in fact, couching was used up until the Middle Ages, and it is still used in remote parts of the world. Furthermore, Susruta’s specificity—particularly in instructing the surgeon on exactly how to hold the salaka—is itself very modern. His attempt to standardize the process of cataract surgery might remind one of the concept of “reliability,” which is defined in the Merriam-Webster Unabridged Online Dictionary as “the extent to which an experiment, test, or measuring procedure yields the same result on repeated trials.” By outlining the specifics of cataract surgery, Susruta helped to ensure that others would be able to perform it with favorable results.
Susruta also recognized that the cloudy lens was something that could be removed, rather than a result of “ill humors,” the prevailing belief in Western medicine in his day.
Dr. Duke Elder, ophthalmologist and historian, found it interesting that while in Hindu medicine cataract was defined by Susutra as an opacity due to a derangement of the intro-ocular fluid, subsequent history is full of fantasies and prejudices concerning its nature.
Regrettably, the earlier advances in medical treatment (pioneered by Susruta, Hippocrates, and others) were gradually lost to the Western world in the first millennium AD, and the status of “surgeon” in Europe was degraded to that of a tradesman. In fact, prior to the eighteenth century, it was the town barber who performed the surgery of the day. The barber’s surgical training was obtained through an apprenticeship. No formal schooling, or even basic literacy, was required. The principal treatment of the day was bloodletting, a reflection of the old prejudice that disease was the result of an imbalance in the “humors” (the bodily fluids). The familiar red and white barber pole represents the outcome of bloodletting: spilled blood and the cloths required to clean up after. The town barber would also extract diseased teeth, treat war wounds, and even administer enemas—in addition to cutting hair. It was only during the eighteenth century that the status of surgeons in Europe was elevated to that of a separate profession. By that time, formal training had become a universal requirement—and the town barber was prohibited from performing surgery other than bloodletting and tooth extraction.
It is often said that we must pay attention to history, or else it will repeat itself. But we must pay attention to history, too, to remember—and to appreciate — the discoveries and breakthroughs that laid the groundwork for life (and medicine) as we know it now. Susruta’s writings on the eye and its diseases, then, will always be relevant, for they are part of the history of modern ophthalmology—and a part of India’s rich and varied history, too.
