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Studies in the Medicine of Ancient India, Part I: Osteology, or the Bones of the Human Body c7.s1: A. The Four Extremities

Studies in the Medicine of Ancient India, Part I: Osteology, or the Bones of the Human Body c7.s1

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Contents

A. The Four Extremities

§ 47. The Phalanges

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Pāṇi-pād-āṅguli, or phalanges of the hands and feet. Both Atreya-Charaka and Suśruta count sixty of these phalanges,

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FIG. 6. OUTLINES OF THE HAND.

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FIG. 7. OUTLINES OF THE FOOT.

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1-8. Carpus, Kūrca.
1. Scaphoid } Kūrca-śiras.
2. Semilunar }
3. Cuneiform.
4. Pisiform.
5. Unciform.
6. Os magnum.
7. Trapezoid.
8. Trapezium. I-V. Metacarpus, Śalākā. a-c. Phalanges, Aṅguli. S. S. Styloid Processes, Maṇika.

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1-7. Tarsus, Kūrca.
1. Os calcis, Pārṣṇi.
2. Astragalus, Kūrca-śiras.
3. Navicular.
4. Cuboid.
5. External cuneiform.
6. Middle ,,
7. Internal ,, I-V. Metatarsus, Śalākā. a-c. Phalanges, Aṅguli. M. M. Malleoli, Gulpha.

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giving three to each finger and toe. The actual number is only fifty-six, there being in reality only two phalanges in the thumb and great toe. Professor Pancoast, however, counts fifteen phalanges in either hand, classing the first metacarpal bone among the phalanges of the thumb,¹ and thus making the total of the phalanges to be fifty-eight. He would seem to consider the trapezium (Fig. 6), one of the carpal bones with which the first metacarpal articulates, to be the real metacarpal of the thumb, and the real homologue of the metacarpals of the other four fingers. According to the usual view the clusters of carpal and tarsal bones contain eight and seven bones respectively. Professor Pancoast’s theory would equalize their numbers by the exclusion of the trapezium. It is interesting to observe that Chakrapāṇidatta’s somewhat obscure remarks on the phalanges seem to indicate his having held a similar view. For he says (§ 11): ‘As to the third joint of the thumb and great toe, it must be understood to be contained within the respective hand or foot,’ that is, within the palm or sole or, in other words, among the metacarpal or metatarsal bones. And he adds: ‘The long bones belonging to the thumb and great toe are also of small size’; that is, he appears to have identified the trapezium as the first metacarpal, and the internal cuneiform bone of the tarsus (Fig. 7) as the first metatarsal. How far the explanation of Chakrapāṇidatta may be the survival of an ancient tradition going back to the time of Atreya and Suśruta, it is, at present, impossible to say. But on the whole it seems more probable that the reckoning of sixty phalanges by the ancient Indian anatomists is based on fancied claims of symmetry (§ 44).

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¹ Dr. Potter’s Compend of Human Anatomy, pp. 49, 50.

§ 48. The Long Bones

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1. *Pāṇi-pāda-śalākā*, or the long bones of the hands and feet. These are the metacarpal and metatarsal bones. Charaka counts twenty of them, five in either hand and foot (§ 4), which agrees with the actual number. Suśruta, in his list (§ 27), aggregates them under the term *tala*, which signifies the palmar and plantar portion of the hand and foot respectively. The Atharva Veda (§ 43) denotes that portion by the term *uchlakha*.

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2. It may here be useful to note that the combined term *tala-kūrca-gulpha*, sole-cluster-ankle, employed by Suśruta in his list (§ 88) denotes the whole (roughly rectangular) portion of the foot and hand, as shown in Figs. 6 and 7, exclusive of the phalanges. That is to say, it signifies the metatarsus (tala), tarsus (kūrca), and malleoli (gulpha) of the foot, and similarly the metacarpus (tala), carpus (kūrca), and styloid processes (maṇibandha) of the hand.

§ 49. Bases or Clusters

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1. Pāṇi-pāda-śalāk-ādhiṣṭhāna, base (prop) of the long bones of the hand and foot; or simply sthāna or pratiṣṭhā, base; or kūrca, cluster (of bones). The first-mentioned term occurs in the lists of Charaka (§ 4) and Bheḍa (§ 12); the second and third in the lists (non-medical) of Yājñavalkya (§ 16) and the Atharva Veda (§ 43) respectively; the fourth in the list of Suśruta. See Figs. 6 and 7.

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2. Ātreya, whose system is reported by Charaka and Bheḍa, appears to have held the opinion that the long bones (metacarpals and metatarsals) were fixed in one bone as their common base. He may have known that this base (the carpus, or tarsus) was really composed of a cluster of small bones, but the term adhiṣṭhāna (or sthāna) which he chose as its name, rather suggests that he thought it to be a single undivided bone. Actual examination of a prepared skeleton, such as Suśruta certainly practised (§ 45), would, of course, have set him right; but it may be doubted whether he ever went beyond a superficial examination of a dead body.

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3. Suśruta’s use of the term kūrca, cluster, which he substitutes for adhiṣṭhāna, base, is by itself sufficient to show that he was aware of the true nature of the ‘base’, as being made up of a cluster of small bones. It is not improbable that he knew even the exact number of the small bones which constitute each cluster (eight in the carpus and seven in the tarsus), but, so far as I know, there is no passage in his Compendium which definitely proves it. Rather inconsistently, but probably in deference to the older view, he continued, for the purpose of his list, to count his ‘cluster’ as one bone. But of course, properly interpreted, this only means that he counted the ‘cluster’ as a composite bone, or rather as a set of bones.

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4. The identity of the organ which Suśruta calls *kūrca*, cluster, may also be inferred from a passage in which he describes its position in the limb. In the sixth chapter of the Anatomical Section (*Śārīra Sthāna*), explaining his doctrine of the ‘vital spots’ (*marman*), he says:

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‘Between the great toe and the toe next to it, there lies the vital spot called *kṣipra*. Upwards of this *kṣipra*, both ways (i.e. exteriorly and interiorly), there lies the vital spot called *kūrca*.’ (Original Text in § 97, cl. 1.)

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Referring to Fig. 7, it will be seen that Suśruta’s *kūrca*, or cluster (of bones), lies on the exterior and interior sides of the foot, beyond the great and second toes. As a matter of fact, the seven bones of the tarsal cluster are in modern Anatomy considered as ‘placed in two rows, side by side, two bones in the external row, five in the internal, as follows: externally, os calcis (No. 1), and cuboid (No. 4); internally, astragalus (No. 2), scaphoid or navicular (No. 3), and the three cuneiform (Nos. 5, 6, 7).’¹ *Mutatis mutandis* these remarks apply also to the carpal cluster. The eight bones of that cluster are now usually considered as ‘placed in two rows, one in front of the other, with four bones in each row.’¹ But they may also be considered as placed (Fig. 6) in two rows, side by side, four bones externally (Nos. 3, 4, 5, 6, unciform, pisiform, cuneiform, os magnum); and four internally (Nos. 1, 2, 7, 8, scaphoid, semilunar, trapezoid, trapezium).

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¹ See Dr. Potter’s *Compend of Human Anatomy*, pp. 48 and 53.

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5. The only difficulty about Suśruta’s *kūrca*, or cluster, arises from the fact that the Traditional Recension of his statement on the skeleton (§ 27) ascribes to him, by implication, the doctrine that there are eight *kūrca*, or clusters, in the four extremities, two in either hand and two in either foot. It has been shown, however, in § 31, that this is a complete error, foisted into the system of Suśruta, in all probability, from the system of Vāgbhaṭa I (§ 37, also pp. 99, 103). The true doctrine of Suśruta, stated by himself in explicit terms (§ 31), knows only four *kūrca*, or clusters, one in either hand, i.e. the carpus, and one in either foot, i.e. the tarsus.

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6. It might be thought that Vāgbhaṭa I derived his doctrine that there are eight *kūrca*, two in either hand and two in either foot, from the circumstance, above referred to, that the small bones of the carpi and tarsi are placed in two rows. One would thus obtain eight rows of small bones, two in either hand and two in either foot; and it might be thought that Vāgbhaṭa I wanted to express that circumstance by his count of eight *kūrca*, or rows. In support of this view it might be said that Vāgbhaṭa I also counts four *gulpha*, or ankle-bones, as well as four *maṇibandha*, or wrist-bones (§ 37). Seeing that there are actually two malleoli (or ankle-bones) in either leg, and two styloid processes (or wrist-bones) in either forearm, it seems a very plausible conclusion that Vāgbhaṭa I was really thinking of the four malleoli and four styloid processes when in his list of bones he enumerates four *gulpha* and four *maṇibandha*; and similarly that he was thinking of the eight rows of small bones in the two carpi and tarsi, when he counted eight *kūrca*. But such a view would credit Vāgbhaṭa I with more consistency and more accurate knowledge of anatomy than he really possessed. How little of both qualities his statement on the skeleton exhibits has been already shown in § 38. A striking proof of his imperfect knowledge of the skeleton is the circumstance that in his list (§ 37) he enumerates both *adhiṣṭhāna* and *kūrca* as two distinct kinds of bone. By the former he understood the carpus and tarsus. This is clear from the term *pratibandhaka*, or interlocker, by which he calls them. He says: ‘There are five long bones, and one bone interlocking them’ (Original Text in § 93). This shows that (whatever Ātreya-Charaka’s view of the real nature of *adhiṣṭhāna* may have been) Vāgbhaṭa I took it to be a single undivided bone, on which the five long bones articulated. But as he had thus provided for the carpus and tarsus, it is difficult to understand what he could have imagined the additional *kūrca* to be. Seeing that all actually existing bones (Figs. 6 and 7), phalanges, metacarpus (or metatarsus), carpus (or tarsus), and styloid processes (or malleoli) were already covered by the terms *aṅguli*, *śalākā*, *pratibandhaka* (or *adhiṣṭhāna*), and *maṇibandha* (or *gulpha*), there was no bone left to be named *kūrca*. It may be doubted whether Vāgbhaṭa I had any idea as to what the Suśrutiyan term *kūrca* meant. He certainly failed to see that it signified the equivalent of the Charakiyan term *adhiṣṭhāna*; and his anatomical knowledge was too imperfect to prevent that failure. It thus came to pass that, dominated by his desire of combining the two systems of Suśruta and Charaka, he not only superfluously counted the *kūrca*, by the side of his *pratibandhaka* (Charaka’s *adhiṣṭhāna*), but actually duplicated its numbers, counting eight *kūrca* instead of four.

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7. In connexion with the cluster of bones (*kūrca*) it may be well to discuss the case of a bone which is not especially enumerated in the list of Suśruta, but which he mentions in the sixth chapter of the Anatomical Section (*Śārīra Sthāna*), in discussing the ‘vital spots’ (*marman*). It is there named by him *kūrca-śiras*, or head of the cluster, that is, head-bone within the cluster. He defines its position as follows:

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‘Below the ankle-joint, but not on both sides, there lies what is called the head of the cluster.’ (Original Text in § 97, cl. 1.)

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By referring to Fig. 7, it will be seen at once that the bone here described as the head of the cluster is the astragalus (No. 2). It forms the lower part of the ankle-joint, and lies below the distal ends of the tibia and fibula with both of which it articulates. In the list of Suśruta (§ 27) it is not specially enumerated, because, of course, it is included in the cluster (*kūrca*) of which it merely forms the head-bone. But in his chapter on the ‘vital spots’ it had to be mentioned separately by the side of the cluster, on account of its being the location of a particularly dangerous spot, in addition to another dangerous spot located in the remainder of the cluster (Nos. 3, 4, 5, 6). The astragalus (No. 2) and the os calcis (No. 1) are the two largest bones of the tarsal cluster, and Suśruta distinguishes them by the names ‘head of the cluster’ (*kūrca-śiras*) and ‘heel’ (*pārṣṇi*) respectively. That fact definitely proves that he was aware of the real nature of the tarsus as being composed of a cluster (*kūrca*) of bones. Ātreya-Charaka, on the other hand, knew nothing of a head of the cluster, and his heel (*pārṣṇi*), as we shall see in the next paragraph, is merely the projecting tuberosity of the os calcis. With him both the astragalus and the os calcis are included in his *adhiṣṭhāna*, or base, and there is nothing to prove definitely that he knew anything of the real composite nature of the organ which he called *adhiṣṭhāna*.

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8. It should be mentioned that Suśruta teaches the existence of four *kūrca-śiras*, or heads of clusters. He says:

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‘There are two ankles, two wrists, and two pairs of cluster-heads. These eight an experienced surgeon should know to be vital spots that are apt to cause diseases.’ (Original Text in § 96, cl. 6.)

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What Suśruta means is, of course, that there is a head-bone in each of the four clusters (*kūrca*), that is, in either of the two carpi and tarsi. The head-bones of the two tarsi are their respective astragali. Those of the two carpi would appear to be their respective semilunar bones (No. 2 in Fig. 6). Charaka (i.e. Ātreya), as has been already indicated, does not mention the existence of any of these four head-bones.

§ 50. The Heel

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*Pārṣṇi*, or the heel. See Fig. 7. This term, as used by Charaka, denotes the backward and downward projection of the os calcis, that is, that portion of it which can be superficially seen and felt, and is popularly known as the heel. Accordingly, in Ātreya’s statement of the skeleton, as reported by Charaka and Bheḍa (§§ 4, 12), the number of heels is rightly said to be two. In the list of Vāgbhaṭa I (§ 37), rather grotesquely a heel is ascribed to each of the four extremities, two in the feet and two in the hands, giving a total of four heels. The reason of this incongruous conception has been explained in § 32. It arose from a false construction of Suśruta’s direction regarding the method of counting the bones of the four extremities, and it actually succeeded, probably on the authority of Vāgbhaṭa I himself, in being received into the Traditional Recension of Suśruta’s statement on the skeleton (§ 27). There can hardly be any doubt that the statement of Suśruta, in its original and genuine form, taught no more than two heels. From the general tenor of it, it is evident that Suśruta knew the true nature of the tarsus; namely, that it is a cluster (*kūrca*) of small bones. The two largest of these small bones he distinguished by special names; namely, the astralagus (No. 2) by *kūrca-siras*, or head of the cluster (§ 49), and the os calcis (No. 2), by *pārṣṇi*, or heel. In his detailed list of the bones (§ 27) he did not enumerate the ‘head of the cluster’ separately; for of course it was implicitly included in the term ‘cluster’ (*kūrca*). But the heel (*pārṣṇi*) he counted separately, either as a concession to the older system of Ātreya, and to popular usage, or, perhaps on the whole more probably, because he did not consider the os calcis as constituting one of the component bones of the cluster (*kūrca*). In all probability Suśruta’s real view of the lower portion of the lower extremity (the portion shown in Fig. 7) was that it was formed by five constituents : 1, phalanges (*aṅguli*); 2, metatarsals (*tala* or *śalākā*); 3, tarsal cluster (*kūrca*) of six small bones (Nos. 2–7 ; 4, ankles (*gulpha*); and 5, os calcis or heel-bone (*pārṣṇi*, No. 1). The view of Ātreya-Charaka differed from the view of Suśruta only in considering the tarsus to consist, not of a cluster of bones, but of a single, undivided supporting bone (*adhiṣṭhāna*), which included the body of the os calcis, but excluded its posterior downward projection, the latter being counted separately and named *pārṣṇi*. In § 65 it will be shown that there exists a similar difference of opinion with respect to the term *hanu* between Suśruta and Ātreya-Charaka. The former uses it as denoting the whole lower jaw-bone (inferior maxillary), while with Ātreya it denotes its (roughly) triangular ‘mental protuberance,’ popularly known as the chin (Fig. 31).

§ 51. Forearm and Leg

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Aratni or *prabāhu*, forearm, and *jaṅgha*, leg. The term *prabāhu* occurs only in certain manuscripts of the Vishnu Smriti (see § 84). In all the three statements, of Ātreya (that is, Charaka and Bheḍa, §§ 4, 12), Suśruta (§ 27), and Vāgbhaṭa I, (§ 37) these two organs are correctly described as consisting of two bones each—viz. the radius and ulna in the forearm, and the tibia and fibula in the leg. In the Atharva Veda (verse 3 in § 43) the figure made by the two bones of the leg is appropriately described as ‘a four-sided frame having its ends firmly knit together’; and this description of course is intended also to apply to the bones of the forearm. See Figs. 8 and 9.

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FIG. 8. FOREARM, Aratni. a. Radius. b. Ulna. c, c. Styloid processes, Maṇika. d. Olecranon process, Kapālikā.

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FIG. 9. LEG, Jaṅgha. a. Tibia. b. Fibula. c, c. Malleoli, Gulpha.

§ 52. Ankles and Wrists

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Maṇika or maṇibandha, wrist-bone, and gulpha, ankle-bone. See Figs. 6 and 7. In literary Sanskrit these terms denote the wrist-joint and ankle-joint respectively; but as anatomical terms they signify more precisely the wrist-bones and ankle-bones, that is, the distal processes of the two bones of the forearm and leg which are known respectively as the styloid processes and the malleoli. By the ancient Indian anatomists, according to their peculiar method (§ 44, cl. 3), they are reckoned as separate bones; but while Ātreya counts them all singly, and thus in the list, reported by Charaka (§ 7), enumerates four wrist-bones and four ankle-bones, Suśruta counts them by pairs, and thus in his list (§ 34), has only two wrist-bones and two ankle-bones, one in each forearm, and one in each leg. The Traditional Recension, of the list of Charaka (§ 4), it is true, counts only two wrist-bones; but it has been shown in §§ 6 and 25 (p. 67) that the original and genuine list (§ 7) must have contained four wrist-bones. On the other hand, the Traditional Recension of Suśruta’s list (§ 27) gives four wrist-bones and four ankle-bones. This, as shown in §§ 31, 41, is also an error, due to the influence of Vāgbhaṭa I (§ 37), who, in pursuance of his aim of combining and harmonizing the two systems of Charaka and Suśruta, adopted Charaka’s way of counting the wrist-bones and ankle-bones.

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2. The truth regarding the way in which Suśruta contemplated the styloid processes and malleoli is clearly brought out by the term valaya, wristlet or anklet, which he applies to them (§ 30). It is obvious from this comparison that he looked upon each pair of styloid processes and malleoli as forming but a single composite bone encircling the lower part of the forearm, or leg, like a wristlet, or anklet (see Fig. 2, p. 80). It must be admitted that this is a rather fanciful way of treating those organs. At the same time, it is quite consistent with Suśruta’s methods; he treats the carpus and tarsus in exactly the same way. For him both are single, composite bones, or clusters (kūrca) as he calls them (§ 49). For the purpose of enumeration in the list of bones, the clusters, though consisting of a number of small bones, are reckoned each as a single bone, or—it would be better to say—as a single system of bones. Similarly, the pairs of styloid processes and malleoli are counted, in the list, each as a single bone, or rather as a single system of bones.

§ 53. Elbow-pan and Knee-cap

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1. Kapālikā or kūrpara, elbow-pan, and jānu or jānuka, knee-cap. There can be no doubt regarding the bones to which these terms refer. They are the olecranon process of the elbow, and the patella of the knee. The former, which ‘in its function and structure resembles the patella’,¹ is not a separate bone, but a process of the ulna (Fig. 8). But by the ancient Indian anatomists, according to their usual practice (§ 44), it is counted as a separate bone. They follow herein our own popular usage which speaks of it as the ‘funny bone’ or ‘crazy bone’.

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¹ Dr. Potter’s Compend of Human Anatomy, p. 47.

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2. The term *kūrpara* is peculiar to Suśruta, who expressly defines it as denoting the homologue of *jānu*, the knee-cap (p. 72), and who may, therefore, have been the first to use it as a denotation of the olecranon process. The term *kapālikā* is peculiar to Ātreya (Charaka and Bheḍa). It means, literally, a small shallow dish, and is therefore identical in meaning with patella, the Latin name of the knee-cap. It well describes the appearance of the olecranon process, which presents, in the ventral view, a concave surface, the so-called great sigmoid cavity (Fig. 8). Accordingly, in this treatise, it has been rendered by ‘elbow-pan’.

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FIG. 10. THE PATELLA, Jānu. From the back, showing interior concave surface.

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3. The term *kapola*, for the elbow-pan, which is found in the Non-medical Version (§ 16), is undoubtedly, as has been explained in § 19, cl. 4, an ancient misreading for *kapāla*, pan, of which *kapālikā* is a diminutive. By way of corroboration it may be mentioned that the Smaller Petersburg Dictionary quotes the form *kapolaka* as a misreading for *kapālaka*, pan. The antiquity of the misreading may be seen from the fact that ancient Sanskrit dictionaries mention *kapoli*, with the meaning knee-cap. The true form, of course, is *kapālī*, a feminine diminutive of *kapāla*, meaning a small pan, or any small pan-like bone, such as the knee-cap or elbow-pan. Similarly, *kapāla* itself is used to denote the larger pan-shaped bones of the cranium (§ 63).

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4. The Atharva Vedic list (§ 43) has the two synonymous terms jānu and aṣṭhīvat. The latter literally means ‘the organ (knee) which possesses a bone (patella)’, and thus, like jānu, comes to denote specifically the knee-cap.

§ 54. Arms and Thighs

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Bāhu, arm, and ūru, thigh. These two terms are employed by Suśruta (§ 27) and Vāgbhaṭa I (§ 37). Charaka uses the fuller terms bāhu-nalaka, reed-like or hollow bone of the arm, and ūru-nalaka, reed-like, or hollow bone of the thigh (§ 4). All three correctly ascribe to either organ a cylindrical bone, the humerus and the femur respectively, with a hollow shaft, the so-called medullary cavity. See Figs. 4 and 5.

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