Who started us on the path of cataract surgery? We’re probably familiar with the remarkable number of pioneers in the past 70 years, beginning with Sir Harold Ridley and continuing to present times with a large group who have pushed cataract surgery into becoming one of the most successful operations of present times. Giving due credit to those living and dead to whom we owe thanks is beyond the scope of this article. But who deserves credit for being the first to perform any type of cataract operation?
Many ophthalmologists, especially those familiar with the history of medicine in India, give credit to Sushruta (also spelled Susruta). Most historians place the time of his life to 600 BC and he lived in Benares, a city on the banks of the river Ganges. He wrote a treatise on surgery called the Sushruta Samhita, only one copy of which is extant today. It was written in Sanskrit and largely unknown to medical historians of the 19th and early 20th centuries.
According to Dr. Shridhar Dwivedi, the Sushruta Samhita contains 184 chapters with descriptions of over 1100 illnesses, 700 medicinal plants and numerous other medicinal preparations. He described diabetes and angina, linking angina to obesity and recommending exercise for diabetics.1
Dr. V.K. Raju, Clinical Professor of Ophthalmology at West Virginia University, notes that the Samhita had eighteen chapters devoted to the eye and described seventy-six different ocular diseases, many of which required surgery. Most notably, Sushruta was the first to perform cataract surgery by couching.2
Consider this scenario. What would you do? The family leads a bilaterally blind person to you. The vision is likely hand motions at best, and the patient can neither get around independently nor see food on the plate. Life expectancy is severely limited. You see two white reflexes through un-dilated pupils. What can be done? You have no slit lamp, no tonometer, no anesthetic or dilating drops and no surgery center. Do you let this patient go home to die or try to do something?
We know that Sushruta advocated for learning medicine in part by dissecting the human body, and that he developed and described a number of surgical tools while teaching that the human hand was the foremost surgical instrument.
Historians credit Sushruta as being the first with the courage to help such patients. One of his instruments was used to enter the eye and push the cataract into the vitreous space. Think of the challenges presented by performing this in the absence of anesthesia and dilation. But he did so and if the patient did not develop an infection, the vision recovered to count fingers with the restored ability to ambulate and see to eat food.
His accomplishments did not stop with eye surgery. D.P. Agrawal, quoting from a book published by the government of India,3 credited Sushruta with developing the basic principles of plastic surgery—release of the skin to cover defects, rotation of flaps and pedicle flaps with attention to proper wound apposition. Sushruta also addressed ethics, warning that improper intervention with surgical maneuvers due to ignorance of the disease process, greed for money, or lack of judgment will lead only to complications. A conscientious surgeon considers the patient as a whole.
Sushruta’s emphasis on ethics has led Dr. Raju to sponsor Sushruta and Charaka Lectures at West Virginia University as well as Sushruta Lectures on History and Ethics at the Wilmer Institute and the University of Pittsburgh. Dr. Raju wants to keep alive the lessons propagated by this remarkable man.
Today, we may not perform cataract surgery by couching, but we would do well to heed Sushruta’s thoughts on ethics while we pay homage to a courageous and pioneering physician.
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Article references:
1. G. Dwivedi, S. Dwivedi, Indian J Chest Dis Allied Sci 2007; 49 243-244
2. V.K. Raju - Personal communication
3. Scientists, Gov’t India Publication (pp 44-720)