Sushrut-samhita Bhanumati Commentary ByChakrapaniDatta

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Sushruta Samhita

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Palm leaves of the Sushruta Samhita or Sahottara-Tantra stored at Los Angeles County Museum of Art, from Nepal, the text is dated 12th-13th century while the art is dated 18th-19th century.

The Sushruta Samhita (सुश्रुतसंहिता, IAST: Suśrutasaṃhitā, literally "Suśruta's Compendium") is an ancient Sanskrit text on medicine and surgery, and one of the most important such treatises on this subject to survive from the ancient world. The Compendium of Suśruta is one of the foundational texts of Ayurveda (Indian traditional medicine), alongside the Caraka-Saṃhitā, the Bheḷa-Saṃhitā, and the medical portions of the Bower Manuscript.^[1][2] It is one of the two foundational Hindu texts on medical profession that have survived from ancient India.^[3][4]

The Suśrutasaṃhitā is of great historical importance because it includes historically unique chapters describing surgical training, instruments and procedures.^[2][5] One of the oldest Sushruta Samhita palm-leaf manuscripts is preserved at the Kaiser Library, Nepal. It is dated to 878 CE.^{[6][contradictory]}

HistoryEdit

Ancient qualifications of a Nurse

That person alone is fit to nurse or to attend the bedside of a patient, who is cool-headed and pleasant in his demeanor, does not speak ill of any body, is strong and attentive to the requirements of the sick, and strictly and indefatigably follows the instructions of the physician.

—Sushruta Samhita Book 1, Chapter XXXIV
Translator: Bhishagratna^[7]

DateEdit

The early scholar Rudolf Hoernle proposed that given that the author of Satapatha Brahmana – an ancient Vedic text, was aware of Sushruta doctrines, those Sushruta doctrines should be dated based on the composition date of Satapatha Brahmana.^[8] The composition date of the Brahmana is itself unclear, added Hoernle, and he estimated it to be about the sixth century BCE.^[8] While Loukas et al. date the Sushruta Samhita to the mid 1st-millennium BCE,^[9] Boslaugh dates the currently existing text to the 6th-century CE.^[10]

Rao in 1985 suggested that the original layer to the Sushruta Samhita was composed in 1st millennium BCE by "elder Sushruta" consisting of five books and 120 chapters, which was redacted and expanded with Uttara-tantra as the last layer of text in 1st millennium CE, bringing the text size to six books and 184 chapters.^[11] Walton et al., in 1994, traced the origins of the text to 1st millennium BCE.^[12]

Meulenbeld in his 1999 book states that the Suśruta-saṃhitā is likely a work that includes several historical layers, whose composition may have begun in the last centuries BCE and was completed in its presently surviving form by another author who redacted its first five sections and added the long, final section, the "Uttaratantra."^[1] It is likely that the Suśruta-saṃhitā was known to the scholar Dṛḍhabala (fl. 300-500 CE, also spelled Dridhabala), which gives the latest date for the version of the work that has survived into the modern era.^[1]

Tipton in a 2008 historical perspectives review, states that uncertainty remains on dating the text, how many authors contributed to it and when. Estimates range from 1000 BCE, 800–600 BCE, 600 BCE, 600–200 BCE, 200 BCE, 1–100 CE, and 500 CE.^[13] Partial resolution of these uncertainties, states Tipton, has come from comparison of the Sushruta Samhita text with several Vedic hymns particularly the Atharvaveda such as the hymn on the creation of man in its 10th book,^[14] the chapters of Atreya Samhita which describe the human skeleton,^[15] better dating of ancient texts that mention Sushruta's name, and critical studies on the ancient Bower Manuscript by Hoernle.^[13] These information trace the first Sushruta Samhita to likely have been composed by about mid 1st millennium BCE.^[13]

AuthorshipEdit

A statue dedicated to Sushruta at the Patanjali Yogpeeth institute in Haridwar. In the sign next to the statue, Patanjali Yogpeeth attributes the title of Maharishi to Sushruta, claims a floruit of 1500 BC for him, and dubs him the "founding father of surgery", and identifies the Sushrut Samhita as "the best and outstanding commentary on Medical Science of Surgery".

Suśruta (Devanagari सुश्रुत, an adjective meaning "renowned"^[16]) is named in the text as the author, who presented the teaching of his guru, Divodāsa.^[17] He is said in ancient texts such as the Buddhist Jatakas to have been a physician who taught in a school in Kashi (Varanasi) in parallel to another medical school in Taxila (on Jhelum river),^[18][19] sometime between 1200 BC and 600 BC.^[20][21] One of the earliest known mentions of the name Sushruta is in the Bower Manuscript (4th or 5th century), where Sushruta is listed as one of the ten sages residing in the Himalayas.^[22]

Rao in 1985 suggested that the author of the original "layer" was "elder Sushruta" (Vrddha Sushruta). The text, states Rao, was redacted centuries later "by another Sushruta, then by Nagarjuna, and thereafter Uttara-tantra was added as a supplement.^[11] It is generally accepted by scholars that there were several ancient authors called "Suśruta" who contributed to this text.^[23]

AffiliationEdit

The text has been called a Hindu text by many scholars.^[10][24][25] The text discusses surgery with the same terminology found in more ancient Hindu texts,^[26][27] mentions Hindu gods such as Narayana, Hari, Brahma, Rudra, Indra and others in its chapters,^[28][29] refers to the scriptures of Hinduism namely the Vedas,^[30][31] and in some cases, recommends exercise, walking and "constant study of the Vedas" as part of the patient's treatment and recovery process.^[32] The text also uses terminology of Samkhya and other schools of Hindu philosophy.^[33][34][35]

The Sushruta Samhita and Caraka Samhita have religious ideas throughout, states Steven Engler, who then concludes "Vedic elements are too central to be discounted as marginal".^[35] These ideas include treating the cow as sacred, extensive use of terms and same metaphors that are pervasive in the Hindu scriptures – the Vedas, and the inclusion of theory of Karma, self (Atman) and Brahman (metaphysical reality) along the lines of those found in ancient Hindu texts.^[35] However, adds Engler, the text also includes another layer of ideas, where empirical rational ideas flourish in competition or cooperation with religious ideas.^[35]

The text may have Buddhist influences, since a redactor named Nagarjuna has raised many historical questions, whether he was the same person of Mahayana Buddhism fame.^[23] Zysk states that the ancient Buddhist medical texts are significantly different from both Sushruta and Caraka Samhita. For example, both Caraka and Sushruta recommend Dhupana (fumigation) in some cases, the use of cauterization with fire and alkali in a class of treatments, and the letting out of blood as the first step in treatment of wounds. Nowhere in the Buddhist Pali texts, states Zysk, are these types of medical procedures mentioned.^[36] Similarly, medicinal resins (Laksha) lists vary between Sushruta and the Pali texts, with some sets not mentioned at all.^[37] While Sushruta and Caraka are close, many afflictions and their treatments found in these texts are not found in Pali texts.^[38]

In general, states Zysk, Buddhist medical texts are closer to Sushruta than to Caraka,^[36] and in his study suggests that the Sushruta Samhita probably underwent a "Hinduization process" around the end of 1st millennium BCE and the early centuries of the common era after the Hindu orthodox identity had formed.^[39] Clifford states that the influence was probably mutual, with Buddhist medical practice in its ancient tradition prohibited outside of the Buddhist monastic order by a precedent set by Buddha, and Buddhist text praise Buddha instead of Hindu gods in their prelude.^[40] The mutual influence between the medical traditions between the various Indian religions, the history of the layers of the Suśruta-saṃhitā remains unclear, a large and difficult research problem.^[23]

Suśruta is reverentially held in Hindu tradition to be a descendant of Dhanvantari, the mythical god of medicine,^[41] or as one who received the knowledge from a discourse from Dhanvantari in Varanasi.^[17]

Manuscripts and transmissionEdit

A page from the ancient medical text, Susruta samhita.

One of the oldest palm-leaf manuscripts of Sushruta Samhita has been discovered in Nepal. It is preserved at the Kaiser Library, Nepal as manuscript KL–699, with its digital copy archived by Nepal-German Manuscript Preservation Project (NGMCP C 80/7).^[6] The partially damaged manuscript consists of 152 folios, written on both sides, with 6 to 8 lines in transitional Gupta script. The manuscript has been verifiably dated to have been completed by the scribe on Sunday, April 13, 878 CE (Manadeva Samvat 301).^[6]

Much of the scholarship on the Suśruta-saṃhitā is based on editions of the text that were published during the nineteenth and early twentieth centuries. This includes the edition by Vaidya Yādavaśarman Trivikramātmaja Ācārya that also includes the commentary of the scholar Dalhaṇa.^[42]

The printed editions are based on just a small subset of manuscripts that were available in the major publishing centres of Bombay, Calcutta and elsewhere when the editions were being prepared, sometimes as few as three or four manuscripts. But these do not adequately represent the large number of manuscript versions of the Suśruta-saṃhitā that have survived into the modern era. These manuscripts exist in the libraries in India and abroad today, perhaps a hundred or more versions of the text exist, and a critical edition of the Suśruta-saṃhitā is yet to be prepared.^[43]

ContentsEdit

Anatomy and empirical studies

The different parts or members of the body as mentioned before including the skin, cannot be correctly described by one who is not well versed in anatomy. Hence, any one desirous of acquiring a thorough knowledge of anatomy should prepare a dead body and carefully, observe, by dissecting it, and examine its different parts.

—Sushruta Samhita, Book 3, Chapter V
Translators: Loukas et al^[9]

The Sushruta Samhita is among the most important ancient medical treatises.^[1][44] It is one of the foundational texts of the medical tradition in India, alongside the Caraka-Saṃhitā, the Bheḷa-Saṃhitā, and the medical portions of the Bower Manuscript.^[1][2][44]

ScopeEdit

The Sushruta Samhita was composed after Charaka Samhita, and except for some topics and their emphasis, both discuss many similar subjects such as General Principles, Pathology, Diagnosis, Anatomy, Sensorial Prognosis, Therapeutics, Pharmaceutics and Toxicology.^[45][46][1]

The Sushruta and Charaka texts differ in one major aspect, with Sushruta Samhita providing the foundation of surgery, while Charaka Samhita being primarily a foundation of medicine.^[45]

ChaptersEdit

The Sushruta Samhita, in its extant form, is divided into 186 chapters and contains descriptions of 1,120 illnesses, 700 medicinal plants, 64 preparations from mineral sources and 57 preparations based on animal sources.^[47]

The Suśruta-Saṃhitā is divided into two parts: the first five chapters, which are considered to be the oldest part of the text, and the "Later Section" (Skt. Uttaratantra) that was added by the author Nagarjuna.^[48] The content of these chapters is diverse, some topics are covered in multiple chapters in different books, and a summary according to the Bhishagratna's translation is as follows:^[49][50][51]

Sushruta Samhita

Book	Chapter	Topics (incomplete)[note 1]	Translation Comments
1. Sutra-sthana 1.I Origin of the Ayurveda: eight divisions, history, definition of Purusha (patient), what is a disease, stages of a disease, classifications [54] 1.II Medical education: qualifications of a student, oath of care, promise of the student to the teacher, ethical prohibitions [55] 1.III Classification of (Original) Samhita: Table of contents, synopsis of the text, skilful and unskilful physicians, how to study for medical practice, need for "constant practice to attain perfection" [56] 1.IV Preface and explanations: Need for clear exposition, defects resulting from unclear statements, duties of a student [57] 1.V Preliminary surgical measures: Types of surgical operations, collecting equipment and accessories, prophylactics, modes of incision, post surgical steps, dressing wounds, instructions to the patient after surgery, measures to remove pain [58] 1.VI Seasons and their influence on health and medicine: effect of weather, change in weather, causes of epidemics, prophylactic measures, natural and unnatural seasons [59] 1.VII Surgical appliances, their use and construction: names, dimensions, use and functions, excellence of each appliance, defect of each appliance, accessories [60] 1.VIII Surgical instruments, their use and construction: handling instruments, sharpening, edging, tempering, maintenance, when should each be used and not used [61] 1.IX Training for surgery: use of dummies and fruits to learn and pre-practice surgery [62] 1.X Qualifications and certification of a physician: effect of weather, change in weather, causes of epidemics, prophylactic measures, natural and unnatural seasons [63] 1.XI Preparing Alkalis, their uses: how to prepare the solutions, external and internal uses, cauterization, potencies, defects, dangers, reaction, preventing abuse [64] 1.XII Cauterization: preparation and process for various injuries and diseases, various types of cauterization [65] 1.XIII Leeching: suitable and unsuitable patients, mode of vitiating dhatu (blood), finding, collecting and keeping leeches, good leeches and bad leeches, post-treatment measures [66] 1.XIV Lymph chyle: menstrual blood and its nature, swellings, venesection, causes of excessive bleeding, causes of scanty bleeding, measures to be adopted in either [67] 1.XV Excretory disorders: nature, locations, theory of why they increase or decrease [68] 1.XVI Ear piercing and bandages: proper piercing, accidents, treatments [69] 1.XVII Swellings: types, suppurating and non-suppurating, causes, symptoms, treatments, dangers of misdiagnosis, anaesthesia, lancing, surgery [70] 1.XVIII Ulcers: classification, preparing medicinal plasters, dressing, evils of not bandaging, benefits of bandaging, when not to bandage, lubricating bandage for faster healing [71] 1.XIX Nursing and management: bed, chamber, prohibited articles, prophylaxis and mantras against monsters and demons, diet, conduct, care [72] 1.XX Food and regimen for patient's recovery: Food and drinks, their role in patient's recovery, salutary regiment, non-salutary regimen [73] 1.XXI Vayu, Pittam and Shleshma: the role and impact of diseases on Vayu, Pittam and Shleshma (body aeration, body fluids) [74] 1.XXII Boils and ulcers, secretions: shapes, types, secretion, role of Vayu, pains and their kinds associated with different types of ulcers, colors of ulcers [75] 1.XXIII Prognosis of ulcers: symptoms, identification of curable and incurable types, palliation, factors which reopen healed ulcer [76] 1.XXIV Classification of diseases, deciding if medicine or surgery is needed: types of diseases, congenital, mental, physical, providential; causes of fever [77] 1.XXV Eight forms of surgery: description, suitability in different cases, avoiding injuries to blood vessels and ligaments, action if accidentally injured [78] 1.XXVI Injuries from splinters: Shalyam, accidental injuries, arrow injuries, necessity for removing arrow shafts [79] 1.XXVII Injuries, extraction of splinters: fifteen methods of extraction, dangers of not extracting splinters completely from a wound [80] 1.XXVIII Progress in treating ulcer: signs of improvement, signs of worsening, fatal symptoms [81] 1.XXIX Disease prognosis, use of omens, augury: Dreams and their analysis for diagnosis [82] 1.XXX Prognosis from sense organs: Testing sensory functions of a patient for symptoms and disease prognosis [83] 1.XXXI - 1.XLVI Various topics [84]
2. Nidana-sthana 2.I Nervous system diseases: causes, pathology, symptoms, prognosis. Epilepsy, Hemiplegia, Torticellis, Facial paralysis, Indistinct speech, etc. [85] 2.II Haemorhoids: classification, causes, pathology, symptoms, prognosis. [86] 2.III Urinary calculli: Aetiology, symptoms, indications, theory on how bladder stones are formed [87] 2.IV Fistula: classification, pathology, symptoms, prognosis. [88] 2.V Skin diseases: classification, aetiology, symptoms, treatment, contagious nature, avoiding its spread, prognosis. [89] 2.VI Urinary diseases: pathology, symptoms, prognosis. [90] 2.VII Dropsy: classification, causes, pathology, symptoms, prognosis. [91] 2.VIII Birth, Difficult labor: causes, classification, symptoms, abortion, miscarriage, prognosis. [92] 2.IX Abscess, Vidradhi: classification, curability, treatment [93] 2.X Mammary glands diseases (women): classification, symptoms, healthy breast milk and its character, abnormal traits, baby care [94] 2.XI Tumors and goitres: classification, symptoms, causes, prognosis [95] 2.XII Andrology and gynecology: genital organ diseases, classification, symptoms, causes, prognosis [96] 2.XIII Kshudra roga: minor diseases, classification, symptoms, causes, prognosis [97] 2.XIV Shuka dosha: classification, symptoms, prognosis [98] 2.XV Fracture and dislocation: causes, features, symptoms, classification, curable and incurable types, treatment, management [99] 2.XVI Mouth, tongue, larynx and lip diseases: classification, causes, symptoms, classification, prognosis [100]
3. Sarira-sthana 3.I Theory of Being: Tattvas, Purusha and Prakriti, Samkhya theories and its use in medical practice, human mind [101] 3.II Reproductive health: classification of semen and menstrual fluid, disorders, treatment, sexual activity for conception, difficulty in conception, causes, description of fetus [102] 3.III Pregnancy: Theory of Sarira (body, matter), Atman (soul), theory on gender formation, signs of pregnancy, care of pregnant woman, fetal development, cravings, twin, time of delivery, care during labor [103] 3.IV Womb, baby development: theory on placenta, limbs, organ development during pregnancy [104] 3.V Human anatomy: Enumeration of limbs, body organs, their numbers, vessels, bones, joints, Sandhis, ligaments, muscles, differences between organs of men and women, reproductive organs [105] 3.VI Marmas, vital organs: classification, numbering and location of organs, different theories on which organs are vital, symptoms associated with specific organs when injured [106] 3.VII Vascular system: classification, numbering and location of Siras (vascular system) [107] 3.VIII Venesection: classification and definition, determining who is fit and who unfit for venesection [108] 3.IX Arteries, Nerves and Ducts: classification, locations, theory on their roles, symptoms in cases of disorder [109] 3.X Nursing, care of pregnant women: needs from conception to parturition, regimen during gestation, diet, natal rites, lactation, infantile diseases, miscarriage and its treatment, management of pregnancy [110]
4. Cikitsa-sthana 4.I Ulcers: causes, symptoms, traumatic and idiopathic ulcers, dosha-originated ulcers, therapeutics, sixty treatments of different types of ulcers [111] 4.II - 4.XXIII Various topics: Treatment of ulcers, wounds, sores, fractures, nervous disorders, urinary infections, skin infections, tumors, swellings, hernia, hydrocele, genital sores, urethra infections, mouth infections, other minor ailments [112] 4.XXIII - 4.XL Various topics on Hygiene: tooth brushing, dental care, face care, hands and feet washing, bathing, exercise, healthy meal, rules on drinking water, benefits of Dahi (yoghurt), good sleep, effect of not taking care of body, improving strength, elixirs, rejuvenators, remedial agents, Soma, tonics, Sneha, Sveda, Emetics, Purgatives, effects of abusing or overdosing medicine and solutions, use of Dhuma (fumes) and Kavala (gargling) for relief from some symptoms. [113]
5. Kalpa-sthana 5.I Preserving food and drink: theory on why food or drink poisons, how to detect poisoned food or drink, treatment of food poisoning [114] 5.II - 5.VIII Various topics on Poisons: Classification, description and treatment of animal poisons, snake bite, rat poisoning, scorpions, spiders, other insect bites [115]
6. Uttara-tantra 6.I-6.XIX Eye disorders, injuries and infections: eye diseases, appendages, causes of eye diseases, symptoms, eyelid infections and their treatment, classification of eye lens problems and prognosis, need and protocols for eye surgery, eye injuries and their treatment [116] 6.XX-6.XXI Ear disorders, injuries and infections: ear diseases, causes and their treatment [117] 6.XXII-6.XXIII Nose disorders, injuries and infections: classification of nose diseases, symptoms and their treatment [118] 6.XXV-6.XXVI Head diseases: classification of head diseases, symptoms and their treatment [119] 6.XXVII-6.XXXVII Malignant grahas: attack by grahas (superhuman influences), symptoms, procedures for sprinkling, fumigation and mantra recitals [120] 6.XXXIX-6.LIII Fever, diarrhea, phthisis, gulma, heart disease, jaundice, hemorrhage, alcoholism, vomiting, asthma, cough: classification, symptoms, causes, prognosis, changes in diet as cure, use of drinks, milk and meat as medicine. [121] 6.LIV-6.LIX Worms, problem urinating, other diseases: classification, symptoms, causes, prognosis [122] 6.LXII Insanity: type, symptoms and treatment [123] 6.LXIV Rules of health: indications and importance of health, knowledge of foods, varying food intake with seasons, effective ways to administer medicines, proper time for taking food and medicines [124] 6.LXV-6.LXVI Glossary and short list: technical terms in the text, their definitions, list of diseases and drugs, various lists and their numbers [125]

Prevention versus cureEdit

Sushruta, states Tipton, asserts that a physician should invest effort to prevent diseases as much as curative remedial procedures.^[126] An important means for prevention, states Sushruta, is physical exercise and hygienic practices.^[126] The text adds that excessive strenuous exercise can be injurious and make one more susceptible to diseases, cautioning against such excess.^[13] Regular moderate exercise, suggests Sushruta, improves resistance to disease and physical decay.^[126] Shushruta has written Shlokas on prevention of diseases.

Human skeletonEdit

The Sushruta Samhita states, per Hoernle translation, that "the professors of Ayurveda speak of three hundred and sixty bones, but books on Salya-Shastra (surgical science) know of only three hundred".^[127] The text then lists the total of 300 as follows: 120 in the extremities (e.g. hands, legs), 117 in pelvic area, sides, back, abdomen and breast, and 63 in neck and upwards.^[127] The text then explains how these subtotals were empirically verified.^[128] The discussion shows that the Indian tradition nurtured diversity of thought, with Sushruta school reaching its own conclusions and differing from the Atreya-Caraka tradition.^[128]

The osteological system of Sushruta, states Hoernle, follows the principle of homology, where the body and organs are viewed as self-mirroring and corresponding across various axes of symmetry.^[129] The differences in the count of bones in the two schools is partly because Charaka Samhita includes thirty two teeth sockets in its count, and their difference of opinions on how and when to count a cartilage as bone (both count cartilages as bones, unlike current medical practice).^[130][131]

SurgeryEdit

Training future surgeons

Students are to practice surgical techniques on gourds and dead animals.

—Sushruta Samhita, Book 1, Chapter IX
Translator: Engler^[35]

The Sushruta Samhita is best known for its approach and discussions of surgery.^[45] It was one of the first in human history to suggest that a student of surgery should learn about human body and its organs by dissecting a dead body.^[45] A student should practice, states the text, on objects resembling the diseased or body part.^[132] Incision studies, for example, are recommended on Pushpaphala (squash, Cucurbita maxima), Alavu (bottle gourd, Lagenaria vulgaris), Trapusha (cucumber, Cucumis pubescens), leather bags filled with fluids and bladders of dead animals.^[132]

The ancient text, state Menon and Haberman, describes haemorrhoidectomy, amputations, plastic, rhinoplastic, ophthalmic, lithotomic and obstetrical procedures.^[45]

The Sushruta mentions various methods including sliding graft, rotation graft and pedicle graft.^[133] Reconstruction of a nose (rhinoplasty) which has been cut off, using a flap of skin from the cheek is also described.^[134] Labioplasty too has received attention in the samahita.^[135]

Medicinal herbsEdit

The Sushruta Samhita, along with the Sanskrit medicine-related classics Atharvaveda and Charak Samhita, together describe more than 700 medicinal herbs.^[136] The description, states Padma, includes their taste, appearance and digestive effects to safety, efficacy, dosage and benefits.^[136]

ReceptionEdit

A number of Sushruta's contributions have been discussed in modern literature. Some of these include Hritshoola (heart pain), circulation of vital body fluids (such as blood (rakta dhatu) and lymph (rasa dhatu), Madhumeha, obesity, and hypertension.^[47] Kearns & Nash (2008) state that the first mention of leprosy is described in Sushruta Samhita.^[137][138] The text discusses kidney stones and its surgical removal.^[139]